PIJ 


OF 


HYDROTHERAPY 

FOR 

STUDENTS  AND  PRACTITIONERS 

OF 

MEDICINE 


Embodying  a  Consideration  of  the 

Scientific  Basis,  Technique  and  Therapeutics 

of  Hydrotherapy  and  some  Allied  Branches  of 

Physiologic  Therapy 


BY 


GEORGE  KNAPP  ABBOTT,  A.  B.,  M.  D. 

Dean  of  Faculty  and 
Professor  of  Physiologic  Therapy  and  Practice  of  Medicine 

in  The  College  of  Medical  Evangelists 
Superintendent  of  The  Loma  Linda  Hospital 


SECOND  EDITION,  REVISED  AND  ENLARGED 
WITH  128  ILLUSTRATIONS 


THE  COLLEGE  PRESS 

LOMA  LINDA,  CAL. 


A 


Copyright.  1914.  by  G.  K.  Abbott 
Lotna  Linda.  California 


PREFACE  TO  SECOND  EDITION 


HPHE  kindly  reception  given  the  first  edition  of  HYDROTHER- 
A  APY,  in  spite  of  jts  many  faults,  and  the  requests  for  a 
text  thoroughly  illustrated,  have  induced  the  author  and  pub- 
lishers to  prepare  this  revised  and  enlarged  edition.  The 
writer  more  than  ever  realizes  the  impossibility  of  making  any 
text-book  a  complete  treatise,  and  especially  so  in  therapeutics, 
the  science  and  art  of  which  are  advancing  so  rapidly. 

Much  new  matter  has  been  added,  among  which  are:  A  chap- 
ter on  Insanity  and  Drug  Addictions,  for  which  the  author  de- 
sires to  thank  Dr.  Jessie  H.  Simpson  of  the  Southern  California 
State  Hospital  for  the  Insane;  a  section  on  Prescription  Writing 
and  Treatment  Combinations;  and  one  on  Hydrotherapentic  Appa- 
ratus and  Treatment  Rooms.  For  conducting  an  original  re- 
search into  the  effects  of  tonic  hydrotherapy  upon  the  metabol- 
ism of  individuals  on  a  low  proteid  diet,  the  author  is  indebted 
to  his  colleague,  Dr.  E.  H.  Risley. 

Many  of  the  new  illustrations  have  been  prepared  in  the 
Laboratory  of  Physiologic  Therapy  of  The  College  of  Medical 
Evangelists  and  in  The  Loma  Linda  Hospital.  For  aid  in  this 
work  the  author  desires  to  acknowledge  the  helpful  assistance 
of  medical  students,  nurses  and  others,  and  especially  medical 
students,  Wm.  Richli  and  L.  D.  Trott,  in  the  preparation  of 
drawings  and  charts.  For  diagrams  and  illustrations  copied 
from  medical  literature  we  have  endeavored  to  give  full  credit. 
For  cuts  furnished  thanks  are  due  to  Dr.  H.  P.  Coile,  the 
Hoffmann  &  Billings  Manufacturing  Company,  James  B.  Clow 
&  Sons,  the  Boston  Surgical  Supply  Company,  and  Mr.  A. 
Campbell. 

Last,  but  not  least,  thanks  are  diie  to  The  Colleg'e  Press  for 
its  endeavor  to  fulfill  the  wishes  of  the  author  in  the  prepara- 
tion of  a  presentable  text. 
Loma  Linda,  California  G.  K.  A. 


(i) 


PREFACE 

NO  apology  need  be  given  for  the  presentation  of  a  work  on 
hydrotherapy.  In  spite  of  the  advances  made  in  modern 
physiologic  therapy  in  general,  hydrotherapy  is  still  a  branch 
of  therapeutics  but  little  used  by  the  general  practitioner.  The 
reason  is  not  difficult  to  find.  As  a  science,  it  receives  but 
scant  attention  from  teachers  of  therapeutics,  and  in  the  medical 
curriculum  is  usually  allotted  a  few  hours  from  the  combined 
course  on  materia  medica  and  therapeutics,  which  is  already 
overcrowded  by  the  presentation  of  a  needlessly  large  number 
of  preparations  of  doubtful  or  very  limited  usefulness.  As  an 
art,  even  less  time  is  devoted  to  it.  It  must,  however,  be 
acknowledged  that  this  brief  consideration  is  a  distinct  advance 
over  twenty  years  ago,  when  the  medical  curriculum  was  quite 
innocent  of  even  a  mention  of  physiologic  therapy. 

It  is  the  author's  firm  belief,  strengthened  by  years  of  experi- 
ence in  the  teaching  of  both  medical  students  and  nurses,  that 
the  student  or  practitioner  should  first  acquire  a  knowledge  of 
the  technique  of  hydrotherapy  in  the  same  way  that  nurses  are 
taught,  i.  e.,  by  actual  drill  under  an  experienced  instructor. 
Insistance  upon  accurate,  personal  observation  of  patients  dur- 
ing their  treatment  will  help  to  strengthen  in  the  mind  of  the 
student  the  necessity  for  close  clinical  observation.  In  the 
management  of  disease,  such  observation  can  not  be  replaced 
by  instruments  of  precision.  In  this  connection  we  can  not 
refrain  from  expressing  our  opinion  that  instruction  in  practical 
therapeutics  and  the  care  of  patients  should  not  be  left  to  the 
later  years  of  the  medical  curriculum. 

With  this  practical  knowledge  of  the  visible  results  to  be 
obtained,  the  student  should  devote  careful  study  to  the  physio- 
logic and  therapeutic  effects  of  each  representative  class  of 
treatments.  This  study  should  include  personal  laboratory 
investigation  into  the  effects  of  thermic  and  mechanical  stimuli 
upon  blood  pressure,  the  heart  rate  and  force,  general  changes 
in  blood  distribution  and  its  cellular  composition,  muscular 

(3) 


4  PREFACE 

capacity,  and  metabolic  changes  as  revealed  by  chemical  exam- 
ination of  the  excretions,  particularly  the  urine. 

In  the  presentation  of  the  subject,  the  author  has  tried  to  pre- 
serve the  closest  connection  between  experimental  physiology 
and  therapeutic  deductions  and  recommendations.  We  have  at 
all  times  endeavored  to  seek  out  a  reason  for  the  results  obtained 
in  practice.  It  is  only  in  this  way  that  varying-  conditions  may 
be  successfully  met. 

The  modern  search  for  "specifics"  has  greatly  aided  in  the 
development  of  scientific  medicine.  The  same  principles,  how- 
ever, must  not,  without  modification,  be  applied  to  hydro- 
therapy.  Specific  results  are  to  be  sought  by  proper  adaptation 
of  the  treatment  to  the  individual  case  in  hand,  rather  than  by 
rigid  adherence  to  this  or  that  type  of  application.  For  this 
reason  physiologic  effects  have  been  dwelt  upon  quite  at  length 
and  have  been  considered  apart  from  the  technique. 

The  subject  of  therapeutics  has  been  presented  with  a  view 
to  the  elucidation  of  basic  principles.  It  is  the  morbid  physio- 
logic or  structural  state  present  in  a  given  disease  that  requires 
treatment  rather  than  the  "disease"  as  an  entity.  Diseases 
most  amenable  to  hydrotherapy  have,  therefore,  been  grouped 
in  classes  according  to  the  general  principles  involved  in  their 
treatment ,  after  an  explanation  of  which,  each  disease  is  given 
particular  attention. 

While  hydrotherapy  is  the  most  important  branch  of  physio- 
logic therapy,  it  is  not  by  any  means  a  "cure  all. ' '  The  border 
line  between  physiologic  and  radical  therapeutics  can  not  be 
drawn  by  disease  lists  but  must  be  settled  by  rational,  conscien- 
tious consideration  of  the  ends  to  be  sought  and  the  trend  of 
the  morbid  condition  in  hand. 

In  presentation  of  this  work,  the  author  lays  no  claims  to 
originality.  In  addition  to  personal  experience,  all  available 
v  .urces  of  information  have  been  drawn  upon.  The  text  matter 
and  diagrams  are  those  used  by  the  author  in  his  lectures  to 
medical  students.  The  part  on  technique  is  an  amplification 
of  a  brief  treatise  on  the  "Technique  of  Hydrotherapy"  pub- 
lished by  the  author  in  1908. 
Loma  Linda,  Cal.  .  G.  K.  A. 


CONTENTS 


PART  I 

SCIENTIFIC  BASIS  AND  PHYSIOLOGIC  EFFECTS 
CHAPTER  I 

THE   PHYSICAL   PROPERTIES   OF   WATER 

Communication  and  Absorption  of  Heat.  Physics  of  Heat. 
Calories.  Specific  Heat.  Latent  Heat.  Thermic  Stimuli. 
Mechanical  Stimuli.  Solvent  and  Chemical  Properties.  Use 
of  Water  in  all  Three  States.  17—25 

CHAPTER     II 
PRINCIPLES   OF   EFFECTS  AND   THERAPY 

Therapy  from  Within.  Warm-  and  Cold-blooded  Animals. 
Intrinsic  Effects.  Reaction.  Types  and  Degrees  of  Reaction. 
Conditions  Influencing  Reaction.  Common  Names  of  Tem- 
peratures. 26—38 

CHAPTER    III 
ANATOMY   AND   PHYSIOLOGY   OF   THE   SKIN 

Muscular  and  Elastic  Tissue.  Blood  Vessels.  Lymphatics. 
39—44 

CHAPTER    IV 
THE   PERIPHERAL   HEART 

Traube-Hering  Waves.  Principles  of  Vascular  Effects. 
Quantity  of  Circulating'  Fluid.  45 — 53 

CHAPTER    V 
ANATOMY  AND   PHYSIOLOGY   OF   THE   SKIN    (CONTINUED) 

Sudoriparous  Glands.  Summary  of  Perspiratory  Influences. 
Sebaceous  Glands.  Absorption  by  the  Skin.  Cutaneous  Res- 
piration. The  Skin  a  Heat  Regulator.  Nerves  of  the  Skin. 
54—61 

CHAPTER    VI 
THE   CIRCULATION— REFLEX    EFFECTS 

Reflex  Areas.  Reflex  Arc.  Special  Reflex  Areas.  Classes 
of  Reflex  Effects.  Special  Reflex  Effects.  62—77 

(5) 


g  CONTENTS 

CHAPTER    VII 
THE  CIRCULATION— HYDROSTATIC  EFFECTS 

Principles  of  Hydrostasis.  Law  of  Antagonism.  Areas  for 
derivation.  78—85 

CHAPTER   VIII 

THE  CIRCULATION -BALANCE   BETWEEN   REFLEX    AND 
HYDROSTATIC   EFFECTS 

Laws  of  Balance.     Examples.     Double  Effects.     86 — 88. 

CHAPTER    IX 
THE  CIRCULATION— BLOOD  PRESSURE 

Force  of  Heart  Beat.  Amount  of  Circulating  Fluid.  Vascu- 
lar Calibre  and  Action.  Miiller's  Laws.  89—99 

CHAPTER    X 
THE  CIRCULATION—CHANGES  IN  COMPOSITION  OF  THE   BLOOD 

Corpuscular  Elements.  Mechanism  of  Distribution.  Vis- 
cosity. Reaction.  Practical  Application.  100 — 110 

CHAPTER    XI 
NITROGENOUS   METABOLISM   AND   EXCRETION 

Effects  of  Cold.  Nitrogen  Economy.  Urea  and  Ammonia. 
Uric  Acid  and  Purin  Bases.  Extractives.  Phosphoric  Acid. 
Sulphates  and  Chlorides.  Effects  of  Heat.  Effects  on  Low 
Proteid  Diet.  111—124 

CHAPTER    XII 
RESPIRATION,    RESPIRATORY   CHANGES    AND    CARBONACEOUS    METABOLISM 

Respiratory  Effects.  Gaseous  Interchange.  Carbon  Diox- 
ide. Oxygen.  125 — 129 

CHAPTER    XIII 
MUSCULAR    CAPACITY 

Effects  of  Cold.  Effects  of  Heat.  Ergograph  and  Dynomo- 
meter  Experiments.  Fatigue  Poisons.  Therapeutic  Applica- 
tions. 130—138 

CHAPTER   XIV 
THE   HEAT  MECHANISM 

Regulation  of  Heat  Production.  Regulation  of  Heat  Loss. 
Experiments  in  Heat  Production  and  Elimination.  Summary. 
139—154 


CONTENTS  7 

PART  II 

THERAPEUTICS 

CHAPTER  xv 

THE  REALM  AND  LIMITATIONS  OF  PHYSIOLOGIC  THERAPY 

Functional  and  Organic  Diseases.  Natural  Means.  Radical 
Means.  Basic  Principles  of  Therapy.  155 — 159 

CHAPTER    XVI 
FEVERS  AND  ANTIPYRETIC   EFFECTS 

Causes  and  Symptoms  of  Fever.  Principles  of  Treatment. 
Rationale  of  Hydrotherapy  in  Infectious  Fevers.  Toxic  Vaso- 
motor  Paralysis.  Medicinal  Antipyretics.  Antipyretic  Effects 
of  Thermic  Applications.  The  Heat  Mechanism  in  Fever. 
Variations  that  Produce  Fever  and  Their  Relation  to  Treat- 
ment. 160—178 

CHAPTER    XVII 
THE   TREATMENT   OF   FEVERS 

Typhoid  Fever.  Malaria.  Measles.  Scarlet  Fever.  Influ- 
enza. 179—211 

CHAPTER    XVIII 
INFLAMMATIONS  AND  ANTIPHLOGISTIC   EFFECTS 

Depletion.  .  Fluxion.  Revulsion.  Pathogenesis  of  Inflam- 
mation. Principles  of  Treatment.  212 — 224 

CHAPTER    XIX 
THE   TREATMENT    OF   INFAMMATIONS 

Inflammations  of  the  Eye.  Erysipelas.  Otitis  Media.  Mas- 
toiditis.  Alveolar  Abscess.  Pharyngitis.  Tonsillitis.  Boils. 
Septicemia.  Poison  Ivy.  Pneumonia.  Bronchopneumonia. 
Pleurisy.  Pericarditis.  Myocarditis.  Rheumatic  Fever.  In- 
fectious Arthritides.  Meningitis.  Biliary  Inflammations. 
Appendicitis.  Pelvic  Inflammations.  Phlebitis.  Mucous  Co- 
litis. Cystitis.  Specific  Urethritis.  225—259 

CHAPTER    XX 
STIMULANTS  AND   TONICS 

Hydriatic  Tonics.  Anemia.  Neurasthenia.  Splanchnic 
Neurasthenia.  Hysteria.  Dyspepsia.  Pulmonary  Tubercu- 


8  CONTENTS 

losis.  Insomnia.  Chronic  Inebriety.  Chronic  Articular 
Rheumatism.  Diabetes.  Sunstroke.  Valvular  Heart  Dis- 
ease. Obesity  with  Fatty  Heart.  Excitant  and  Stimulating- 
Effects.  Uterine,  Vesical  and  Intestinal  Stimulants.  260 — 299 

CHAPTER    XXI 
SEDATIVE   EFFECTS 

General  Sedatives.  Pure  Sedatives.  Tonic  Sedatives.  Lo- 
cal Sedatives.  Insomnia.  Chorea.  Paralysis  Agitans.  Spas- 
tic Spinal  Paralyses.  Locomotor  Ataxia.  Parenchymatous 
Goitre.  The  Relief  of  Pain.  Ulcer.  Hemorrhoids.  Neu- 
ralgia. Tenesmus.  Dysmenorrhoea.  Renal  and  Biliary  Colic. 
Burns.  Sprains  and  Bruises.  Fractures.  Headache.  300 — 330 

CHAPTER    XXII 
EXPECTORANT   EFFECTS 

Colds.  Acute  Coryza.  Acute  Bronchitis.  Croup.  Asthma. 
Chronic  Bronchitis.  331 — 336 

CHAPTER    XXIII 
DIAPHORETIC  AND   DIURETIC   EFFECTS 

Diaphoretic  Effects.     Diuretic  Effects.     337-340 

CHAPTER    XXIV 
SYSTEMIC  AND   METABOLIC   DISEASES 

Obesity.  Icterus.  Systemic  Poisoning-.  Internal  Conges- 
tions. Gout  and  Gouty  Rheumatism.  Bright's  Disease. 
Uremia  and  Eclampsia.  341—362 

CHAPTER    XXV 
PEPTOGENIC  EFFECTS 

Atonic  Dyspepsia.  Gastrectasia.  Hypochlorhydria.  Hyper- 
chlorhydria.  363—369 

CHAPTER    XXVI 
HEMOSTATIC   EFFECTS 

Epistaxis.  Pulmonary  Hemorrhage.  Gastric  Hemorrhage. 
Ltenne  Hemorrhage.  Apoplexy.  370—372 

CHAPTER    XXVII 
HYDROTHERAPY   IN   SURGERY 

Preparatory  Treatment.     Immediate  Car,.     Surgical  Shock. 


CONTENTS  9 

Vasomotor  and  Cardiac  Changes.  Hydriatic  Treatment  of 
Shock.  Drug-  Treatment  of  Shock.  After  Treatment.  373— 
393 

CHAPTER    XXVIII 
INSANITY  AND   DRUG  ADDICTIONS 

Mania.  Depressed  Cases.  Morphinism.  Alcoholism.  394 
—396 

PART  III 

TECHNIQUE  OF  HYDROTHERAPY 
CLASSIFICATION  OF  PROCEDURES  AND  GLOSSARY  OF  TERMS 
Basis  of  Classification.     Definitions.     397 — 400 

LOCAL  APPLICATIONS  OF  HEAT 

Fomentations.  Hot  Compress.  Stupes.  Alternate  and 
Simultaneous  Hot  and  Cold  Treatments.  Hot -Water  Bottles. 
Hot  Water  Coil.  Radiant  Heat.  401—409 

LOCAL  APPLICATIONS   OF  COLD 

Cold  Compress.  Ice  Pack.  Ice  Cravat.  Ice  Bag-.  Cold 
Water  Coil.  409—412 

HEATING  COMPRESSES 

Moist  Chest  Pack.  Dry  Chest  Pack.  Moist  Abdominal  Ban- 
dage. Heating  Throat  Compress.  Heating  Joint  Compress. 
Medicated  Compresses.  412 — 417 

POULTICES 

White  Clay  and  Glycerine.     Charcoal.     417 — 418 

TONIC  FRICTIONS 

Cold  Mitten  Friction.  Wet  Hand  Rub.  Cold  Towel  Rub. 
Wet  Sheet  Rub.  Dripping  Sheet  Rub.  Ice  Rub.  Salt  Glow. 
418—423 

SPONGING 

Hot,  Cold  and  Tepid  Sponge.  Saline  Sponge.  Alkaline 
Sponge.  Vinegar  and  Salt  Rub.  Alcohol  Rub.  Witchhazel 
Rub.  Menthol  Rub.  Soap  Wash.  423—425 

RUBS  AND   FRICTIONS 

Centripetal  Friction.  Oil  Rub.  Talcum  Rub.  Dry  Fric- 
tion. 425—430 


w  CONTENTS 

BATHS 

Partial  Immersion.  Hand  and  Arm  Bath.  Foot  Bath.  Leg 
Bath.  Sitz  Bath.  Hot  Half  Bath.  Full  Immersion  Baths. 
Hot,  Cold  and  Neutral  Tub  Baths.  Brand  Bath.  Graduated 
Bath.  Cold  Shallow  Bath.  Hydro- Electric  Baths.  Medicated 
Baths.  Nauheim  Bath.  Oxygen  Bath.  Russian  Bath.  Vapor 
Bath.  Turkish  Bath.  Superheated  Air  Bath.  Electric  Light 
Bath.  430—452 

SHAMPOOS 

Swedish  Shampoo.  Tub  Shampoo.  Turkish  Shampoo.  452 
—454. 

PACKS 

Full  Hot  Blanket  Pack.  Dry  Blanket  Pack.  Trunk  Pack. 
Pelvic  Pack.  Hip  and  Leg  Pack.  Hot  Packs  with  Ice  Bags. 
Electro-thermal  Pack.  Evaporating,  Neutral,  Heating  and 
Sweating  Wet  Sheet  Packs.  Heating  Trunk  Pack.  Hot  and 
Heating  Trunk  Pack.  Heating  Pelvic  Pack.  454—467 

SPRAYS  AND  DOUCHES 

Shower  Bath.  Spray  Bath.  Revulsive,  Alternate,  Percus- 
sion and  Spray  Douches.  Spray  and  Douche  Prescriptions. 
Affusions.  Pail  Pour.  467—476 

ENEMATA 

Hot,  Cold  and  Graduated  Enemata.  Cold  and  Alternate 
Rectal  Irrigation.  Coloclyster.  Saline  Enema.  Proctoclysis. 
Soapsuds,  Oil,  Asafoetida,  Glycerine  and  Epsom  Salts,  Starch, 
Astringent,  Quassia,  Quinin  Enemata.  476 — 486 

VAGINAL  IRRIGATION 

Hot,  and  Alternate  Hot  and  Cold  Vaginal  Irrigation.  Dis- 
infectant and  Styptic  Vaginal  Irrigation.  486—489 

PRESCRIPTION   WRITING  AND   TREATMENT  COMBINATI    NS 

General  Rules,   Illustrations  and  Prescriptions.     490 — 494 

HYDROTHERAPEUTIC   APPARATUS  AND   TREATMENT   ROOMS 

General    Treatment    Rooms.       Fomentation    Tank.      Steam 
Leg  Tubs.     Foot  Tubs.      Bath   Tubs.      Sitz  Tubs 
•tectric  Light  Cabinets.     Russian  and  Turkish   Bath   Rooms. 
Enema  and  Douche  Outfit.     Spray  and  Douche  Con- 
troller.    Douches.     495     510 


ILLUSTRATIONS 


PLATES 

PLATE  OPP.    PAGE 

Frontisplate,  Reflex  arc  from  skin  to  heart 

I  Diagrammatic  section  of  skin  40 

II  Visceral  sympathetic  nerves  62 

III  The  innervation  of  the  heart  68 

IV  The  effect  of  baths  on  blood  pressure  98 

V  Portable  tub  on  wheels  182 

VI  Portable  tub  with  raising  device  182 

VII  The  Coile  bed  bath  186 

VIII  Continuous  cooling  in  typhoid  fever  186 

IX  Sudorific  treatment  in  influenza  210 

X  Depletion  by  simultaneous  heat  and  cold  212 

XI  Hot  and  cold  immersion  for  infected  hand  232 

XII  Fomentations  to  chest  for  pleurisy  246 

XIII  Ice  pack  to  knee  in  acute  arthritis  250 

XIV  Fomentations  to  knee  in  chronic  arthritis  250 

XV  Local  superheated  air  bath,  preparing  348 

XVI  Local  superheated  air  bath,  using  348 

XVII  Hot  air  bath  in  bed  356 

XVIII  The  Winternitz  pack  with  hot  water  coil  366 

XIX  The  Winternitz  pack  with  hot-water  bottle  366 

XX  The  continuous  flowing  bath  396 

XXI  The  sedative  wet  sheet  pack  396 

XXII  Wringing  a  fomentation  by  hand  402 

XXIII  A  fomentation  tank  with  wringers  402 

XXIV  Steam  boxes  for  heating  fomentations,  closed       404 

XXV  Steam  boxes  for  heating  fomentations,  in  use  404 

XXVI  Hot-water  bottles  408 

XXVII  Ice  bags  408 

XXVIII  Square  chest  pack,  roller  chest  pack,  and  moist 

abdominal  bandage  412 

XXIX  The  roller  chest  pack,  applying  414 

XXX  The  roller  chest  pack,  finished  414 


(a) 


ILLUSTRATIONS 


XXXI 

XXXII 

XXXIII 

XXXIV 

XXXV 

XXXVI 

XXXVII 

XXXVIII 

XXXIX 

XL 

XLI 

XLII 

XLIII 

XLIV 

XLV 

XLVI 

XLVII 

XLVI  1 1 

XLIX 

L 

LI 

LII 

LIII 

LIV 

LV 


416 
416 

418 
418 
420 
422 
422 
436 
436 
448 


The  square  chest  pack,  applying- 
The  square  chest  pack,  finished 
The  moist  abdominal  bandage 
The  cold  towel  rub 
The  cold  mitten  friction 
The  wet  sheet  rub,  applying  the  sheet 
The  wet  sheet  rub,  rubbing  the  patient 
The  sitz  bath 
The  hot  half  bath 
The  Russian  bath  room,  in  use 
The  Russian  bath  room,  open,  showing  shower    448 
The  Turkish  bath  cabinets  .  450 

Superheated  air  bath,  ready  for  use  450 

Superheated  air  bath,  patient  in  Turkish  towel- 
ing suit  450 
Superheated  air  bath,  in  use  450 
Electric  light  bath  cabinet,  upright  form  452 
Electric  light  bath  cabinet,  horizontal  form  454 
The  hot  blanket  pack  460 
The  evaporating  wet  sheet  pack  460 
The  author's  hydrotherapy  control  table  468 
A  seepage  apparatus  484 
Continuous  proctoclysis  484 
Adjustable  standard  for  enema  and  douche  cans  502 
Enema  cans  arranged  for  alternate  hot  and  cold 

rectal  irrigation  502 

Rectal  and  vaginal  tubes  502 


TEXT  FIGURES 


FIGURE 

1 

2 

3 
4 


Expansion  of  water  at  different  temperatures 
Comparative  thermometer  scales 
Chart  of  wave  energies 

Diagram  illustrating  time  factor  in  intrinsic  and  reac- 
tionary effects 

Origin  of  lymphatic  vessels   in  a  papilla  of  the  hand 
(Sappey) 

Superficial  lymphatics  of  the  arm  (Sappey) 

Valves  of  mc-senteric  ehylifcrous  vessels  (Delamere) 


PAGE 


ILLUSTRATIONS  13 

8  Blood    pressure    tracing-,     showing:    Traube-Hering' 

curves  taken  from  a  dog  under  artificial  respiration       46 

9  Blood    pressure     tracing,     showing    Traube-Hering 

curves  taken  from  a  dog"  after  cessation  of  respiration     46 

10  Rhythmical   vasomotor  waves  of  blood  pressure  in  a 

dog-  47 

11  Tone  waves  in  heart  muscle  48 

12  Periodic  fluctuations  in  blood  pressure  tracing  taken 

from  man  at  rest  49 

13  Diagram  of  glomerulus  and  uriniferous  tubule  55 

14  Diagram  of  coil  gland  of  skin  and  vascular  network  55 

15  Diagram  to  show  vasomotor  reflex  arc  (Howell)  66 

16  Anterior  reflex  areas  (Kellogg)  70 

17  Sphygmograph  tracing-  showing-  effect  of  proximal  ap- 

plication, on  pulse  wave  (Kellogg)  74 

18  Plethysmographic  tracing-  showing-  effect  of  proximal 

application  on  volume  curve  (Kellog-gO  74 

19  Diagram  showing-  congestion  of  lungs  75 

20  Diagram  showing  reflex  action  of  ice  bag-  on  cong-ested 

lung  75 

21  Volume   curve   of  rig'ht  arm  during-  a  hot  sitz  bath, 

showing  derivative  effect  (Winternitz)  80 

22  Volume  curve  of  right  arm  during  cold  sitz  bath,  show- 

ing retrostatic  effect  (Winternitz)  81 

23  Curve  showing  effect  of  a  sudden  rise  in  the  arterial 

resistance  on  the  output  and  volume  of  the  ventricles 
(Starling-)  90 

24  Cardiometer  tracing  showing  effect  of  increasing  the 

volume  of  circulating  fluid  on  the  total  output  and 

volume  of  the  heart  (Roy)  91 

25  Faught's  sphygmomanometer  96 

26  Riva-Rocci  sphyg-momanometer  97 

27  Gartner's  tonometer  98 

28  Chart  showing-  effect  of  cold  on  blood  count  and  hemo- 

globin 101 

29  Plethysmographic  tracing  of  spleen,  showing  the  spon- 

taneous   rhythmical    contractions    of    this    organ 
(Howell)  104 

30  Chart  showing  effect  of  thermic  procedures  on  alka- 

linity of  blood  106 


n  ILLUSTRATIONS 

31  Chart  showing  effect  of  thermic  procedures  on  acidity 

of  urine 

32  Curve  showing  effect  of  cold  treatment  on  fecal  and 

urinary  nitrogen  (Strasser) 

33  Curve  showing  effect  of  cold  treatment  on  urea,  phos- 

phates and  ammonia  (Strasser) 

34  Curve  showing  effect  of  cold  treatment  on  the  oxida- 

tion of  purins  (Strasser)  H7 

35  Curve  showing  effect  of  cold  treatment  on  the  alka- 

line and  earthy  phosphates  (Strasser) 

36  Mosso's  ergograph 

37  Ergograms  showing  effect  of  cold  bath  on  muscular 

capacity  13- 

38  Ergograms  showing  effect  of  graduated  bath  on  mus- 

cular capacity  133 

39  Ergograms  showing  effect  of  graduated  bath  on  fa- 

tigue 133 

40  Ergograms  showing  effect  of  cold  wet  sheet  rub  on 

fatigue  134 

41  Ergograms  showing  effect  of  warm   bath  and   warm 

douche  on  fatigue  134 

42  Tracings  showing  effect  of  caffeine  on  voluntary 

muscle  (Wood)  136 

43  Rubner's  chart  showing  manner  of  heat  loss  at  differ- 

ent temperatures  143 

44  Diagram  illustrating  heat  regulating   mechanism 

(Wood)  145 

45  Reichcrt's  water  calorimeter  146 

46  Chart  showing  effect   of   physical   measures  on  heat 

elimination  (Winternitz)  149 

47  Diagram  showing  quantitative   relation  between  tem- 

perature-raising and  temperature-lowering  capacity 

of  different  treatments  173 

48  Burr  portable  bath"  181 

49  Maragliano's   chart   of    temperature    and    peripheral 

vasoconstriction  in  malaria  201 
Capillaries  as  affected  by  irritant  and    inflammation 

<  Brunton)  218 

51     A pparatns  for  treating  inflammations  of  eye  226 

The  window  tent  for  the  fresh  air  treatment  of  fevers  235 

V>     The  perineal  (louche  258 


ILLUSTRATIONS  15 

54  Diagram    showing"    dynamic    conditions    in    valvular 

heart  disease  284 

55  Physical  chart  of  heart  and  liver  as  affected  by  Nauheim 

bath  and  tonic  hydrotherapy  290 

56  Diagram  to  show  the  effects  of  heat  and  cold  in  lessen- 

ing the  pain  of  inflammation  304 

57  Inhaler  for  medicated  steam  (Kellogg)  334 

58  An  improved  croup  kettle  (Dieffenbach)  335 

59  Three  sizes  of  radiant  heat  408 

60  The  Winternitz  coil  411 

61  Plan  of  fomentation  tank  497 

62  Steam  coil  for  heating  fomentation  water,  obverse  498 

63  Steam  coil  for  heating  fomentation  water,   reverse  498 

64  Plan  of  steam  box  499 

65  Molasses  faucet  outlet  for  leg  tub  500 

66  Flume  gate  outlet  for  leg  tub  500 

67  Plan  of  top  of  control  table  504 

68  Martinson  mixer,  showing  its  construction  505' 

69  Niedecken  mixer,  showing  working  parts  506 

70  The  jet  douche,  the  spray  douche,  the  fan  douche  507 

71  Plan  of  seat  spray  for  the  perineal  douche  508 

72  Wall  control,  showing  front  and  side  elevation  plans  509 


CHAPTER  I 
THE  PHYSICAL  PROPERTIES  OF  WATER 

IN  the  application  of  any  therapeutic  agent,  it  is  essential  to 
obtain  an  understanding  of  those  properties  of   the    agent 
itself,  of  which  particular  use  is  made  in  the  treatment  of  dis- 
ease.    In  the  case  of  water,  these  essential  properties  may  be 
discussed  under  the  following  heads : — 

1.  Its  ability  to  comnmnicate  and  absorb  large  quantities  of  heat 
by  contact. 

(a)  Specific  heat.     (£)  Latent  heat. 

2.  Its  great  temperature-conducting  capacity — thermic  stimulation . 

3 .  The  perfect flitidity  of  water — its  use  in  mechanical  stimulation . 

4.  Its  solvent  properties  and  use  in  nutritive  and  metabolic  changes. 

5.  Existence  of  water  in  the  three  states  of  matter  within  a  short 
range  of  temperature — practicability  of  applying  it  to  the  body  in  all 
these  three  states. 

1.  The  Communication  and  Absorption  of  Heat.  Hydrother- 
apy  consists  chiefly  in  the  application  of  heat  and  cold  to  the 
body  by  means  of  water.  Its  most  helpful  results  are  obtained 
from  the  heat  applied.  In  its  most  scientific  and  practical 
phases  it  is  a  study  of  thermotherapy.  This  being  true,  in  the 
power  of  water  to  communicate  and  absorb  large  quantities  of 
heat,  without  itself  undergoing  a  corresponding"  change  in  tem- 
perature, lies  its  most  useful  property.  To  rightly  apply  so 
powerful  an  agent,  one  should  understand  the  physics  of  heat 
as  it  applies  to  water.  A  brief  summary  of  this  subject  will 
not,  therefore,  be  out  of  place. 

2  (17) 


IS 


PROPERTIES  OF  WATER 


PHYSICS  OF  HEAT 

When  heated,  the  particles  of  any  substance  separate  slightly, 
thus  moving  more  freely  upon  each  other  when  hot  than  when 
cold.  Solids  are  thus  made  softer,  more  porous,  and  pliable. 
With  some  solids  this  is  so  marked  that  they  may  be  moulded 
into  various  shapes  even  before  hot  enough  to  become  liquids. 
The  body  tissues  are  likewise  made  soft  and  pliable  through  the 
influence  of  heat.  The  skin  is  expanded,  the  muscles  relaxed, 
and  the  blood-vessels  dilated. 


4.  3 


V\K.  1.     Expansion  of  water  at  temperatures  from  0°  C.  to  100°  C. 

In  general,  heat  expands  all  substances,  some,  however,  to  a 
greater  degree  than  others.  Each  metal,  for  example,  shows  a 
definite  degree  of  increase  in  bulk  when  heated.  Water  ex- 
pands, occupying  more  space  as  its  temperature  increases  above 
4  C.  (39.2°  F.).  Nearly  all  substances  continue  to  contract 
indefinitely  under  the  influence  of  cold;  /.  <?.,  the  withdrawal  of 


INTENSITY  OF  HEAT 


19 


heat.  But  water,  after  cooling-  to  4°  C.,  expands  until  frozen. 
Four  degrees  C.,  or  39.2°  F.,  is,  therefore,  said  to  be  the  point 
of  maximum  density  of  water.  (Fig.  1.)  At  this  temperature 
a  given  weight  of  water  occupies  (is  crowded  into)  the  least 

possible  space.  It  is  because  of  this 
change  (expansion)  in  freezing  that 
ice  floats.  If  water  continued  to  con- 
tract on  freezing,  it  then  being  denser, 
would  sink  to  the  bottom,  and  so  re- 
main frozen  for  a  much  longer  time, 
as  solar  heat  loses  its  effect  in  pene- 
trating so  far.  Did  this  occur,  only 
very  shallow  bodies  of  water  would 
ever  entirely  thaw  out  at  tempera- 
tures common  to  temperate  and  frigid 
zones. 

Degrees  or  the  Intensity  of  Heat. 
The  intensify  or  degree  of  heat  is 
measured  by  a  thermometer,  (ther- 
mo — heat,  meter — measure).  Only 
the  Fahrenheit  and  Centigrade  scales 
need  be  described.  The  Fahrenheit 
thermometer,  more  commonly  used 
for  domestic  and  clinical  purposes 
will  be  described  first.  The  freezing 
point  of  water  is  marked  as  32°  F., 
that  is,  32°  above  the  zero  or  starting 
point  of  this  scale.  Water  boils  at 
212°  F.,  /.  e.,  180°  F.  above  freezing. 
The  Centigrade  thermometer  is  a 
more  simple  instrument,  as  the  freez- 
ing point  of  water  is  marked  0°,  while 
the  boiling  point  is  marked  100°. 
From  this  we  see  that  32°  Fahrenheit 
corresponds  to  0°  C.,  and  212°  F. 
corresponds  to  100°  C.,  and,  there- 
fore, 180  Fahrenheit  degrees  (212  minus  32)  are  the  equiva- 
lent of  100  Centigrade  degrees,  or  1.8°  F.  equal  1°  C.  (Fig.  2.). 


irenheit 

Centigrade 
/~\ 

230 

10  1 

220 

L 
"wo 

200 
190 

90 

180 

iro 

80 

160 

70 

150 

140 

60 

130 
120 

50 

110 
100     BODY 

40 

" 

30  ; 

70 

20 

M 

50 

10  ; 

40 

;      rattxiM' 

omT  rt 

1;  30    "  I*™ 

B 

-! 

J 

Fig.  2.    Comparative  ther- 
mometer scales. 


SO  PROPERTIES  OF  WATER 

l-:,,i(h-alnit  Readings.  To  change  a  given  reading:  on  the  Cen- 
tigrade scale  to  Fahrenheit,  it  is  necessary  first  to  multiply  by 
9-5  (180-100).  This  gives  the  number  of  Fahrenheit  degrees 
above  the  freezing-  point.  Since  this  point  on  the  Fahrenheit 
scale  is  32°  above  zero,  32  should  be  added  to  the  result  to 
obtain  the  correct  Fahrenheit  reading.  For  example,  find  the 
Fahrenheit  reading  which  corresponds  to  35°  C.  Multiplying 
35°  by  9-5  gives  63°  above  freezing:;  adding-  32°  gives  95°  F. 

To  obtain  the  correct  Centigrade  reading-  of  a  given  Fahren- 
heit temperature, -it  is  only  necessary  to  reverse  the  process. 
Take,  for  example,  98.6°  F.,  the  normal  body  temperature  by 
mouth.  This  is  66.6°  (98.6  minus  32)  above  freezing-;  66.6° 
multiplied  by  5-9  equals  37°  C.  Since  0°  C.  is  the  freezing- 
point,  this  is  the  correct  Centigrade  reading. 
Condensed  Rules: — 

To  change  Centigrade  to  Fahrenheit,  multiply  by  9-5  and 
add  32. 

To  change  Fahrenheit  to  Centigrade,  subtract  32  and  multi- 
ply by  5-9. 

Heat  Units  or  Quantity  of  Heat,  (a)  SPECIFIC  HEAT.  The 
amount  of  heat  required  to  raise  a  gram  of  water  1°  C.  is  called 
a  heat  unit,  or  calorie.  The  large  Calorie  (written  with  an 
initial  capital)  is  the  amount  of  heat  necessary  to  raise  1000 
grams  (1  liter)  of  water  1°  C.,  and  is,  therefore,  equal  to  1000 
small  calories. 

The  amount  of  heat  that  would  raise  the  temperature  of  a 
given  weight  of  water  1°  C.  would  raise  the  temperature  of  the 
same  weight  of  mercury  30°  C.  Therefore,  one  gram  of  mer- 
cury in  being  heated  through  1°  C.  would  absorb  only  1-30  of 
a  calorie,  /'.  e.,  1-30  of  the  amount  of  heat  absorbed  by  the  same 
weight  of  water  in  being  heated  through  1°  C.  From  this  fact 
it  will  be  seen  that  water  absorbs  a  larg-e  amount  of  heat  with- 
out manifesting  a  corresponding  change  in  temperature;  while 
a  small  amount  of  heat  produces  a  considerable  change  in  the 
temix'rature  of  mercury. 

The  heat  necessary  to  raise  a  given  weight  of  water  1°  is 

;iter  than  that  of  any  other  substance.     Therefore,  water  is 

said  to  have  a  high  specific  heat.     Specific  heat  is  the  capacity  of 


LATENT  HEAT  21 

a  substance  for  absorbing  heat  as  compared  with  the  capacity  of  a 
standard  substance.  More  accurately,  it  is  the  amount  of  heat  a 
given  weight  of  a  substance  .absorbs  in  being"  raised  in  tempera- 
ture 1°  C.  as  compared  with  the  amount  of  heat  necessary  to 
accomplish  the  same  rise  in  temperature  in  the  same  weight  of 
a  standard  substance.  Since  water  absorbs  more  heat  than  any 
other  substance,  it  is  taken  as  the  standard.  A  gram  of  mer- 
cury, absorbing  only  1-30  the  amount  of  heat  absorbed  by  1 
gram  of  water,  is  said  to  have  a  specific  heat  of  1-30  that  of 
water.  Copper  has  a  specific  heat  of  1-12  that  of  water. 

It  will  be  seen  from  the  preceding  discussion,  that  a  large 
amount  of  heat  is  stored  in  hot  water.  It  is  this  high  specific 
heat  of  water  that  makes  it  especially  valuable  in  applying  heat 
to  the  body.  A  pound  of  hot  water  will  communicate  thirty 
times  as  much  heat  to  the  body  as  a  pound  of  mercury.  And 
conversely,  a  pound  of  cold  water  will  abstract  from  the  body 
thirty  times  as  much  heat  as  a  pound  of  mercury.  In  each 
case  the  temperature  of  the  water  or  the  mercury  will  be 
changed  only  1°.  The  hot  water  not  only  stores  up  a  great 
amount  of  heat,  but  it  communicates  this  very  readily  to  things 
with  which  it  comes  in  contact.  Conversely,  cold  water  very 
readily  absorbs  heat  by  contact  with  other  bodies.  Hence,  if 
applied  to  the  human  body,  it  quickly  cools  the  skin,  adjacent 
tissues,  and  their  blood  current. 

(b)  LATENT  HEAT.  A  thermometer  placed  on  ice  as  it  is 
melting  and  another  placed  in  the  water  just  after,  register  ex- 
actly the  same  degree  or  intensity  of  heat,  viz.,  0°  C.  Since  it 
requires  heat  to  melt  ice,  a  mere  change  in  physical  state,  we 
may  very  naturally  ask,  What  becomes  of  this  heat  when  the 
solid  changes  to  a  liquid  ?  It  is  not  apparent  nor  manifest  by  a 
change  in  the  thermometer.  We  may  call  it  hidden  or  latent 
heat.  By  careful  experimentation,  it  is  found  that  an  astonish- 
ingly large  quantity  of  heat  is  absorbed  in  this  process;  in  the 
melting  of  one  gram  of  ice,  sufficient,  in  fact,  to  raise  the  tem- 
perature of  one  gram  of  water  79.2°  C.  This  gram  of  ice  in 
melting,  therefore,  absorbs  79.2  calories,  with  no  consequent 
rise  in  the  temperature,  as  measured  in  degrees.  This  amount 
of  heat  is  made  latent.  The  latent  heat  of  fusion,  or  melting  of 


gg  PROPERTIES  OF  WATER 

ice,  is  thus  fixed  at  79.2  calories.  This  is  the  reason  ice  cools 
the  body  so  much  more  rapidly  than  cold  water,  every  gram  of 
ice  that  melts  abstracting  nearly  eighty  times  as  much  heat  as 
the  same  weight  of  water  warmed  through  1°  C.  The  value  of 
the  ice  rub  is  thus  amply  demonstrated.  For  the  same  reason 
an  ice  bag  produces  a  greater  intensity  of  effect  than  a  cold 
compress. 

The  same  principle  applies  to  the  boiling  of  water  or  the  con- 
densing of  steam,  except  that  a  much  greater  number  of  heat 
units  is  respectively  made  latent  or  given  off.  Water  at  the 
boiling  point  registers  the  same  degree  of  heat  as  steam  just 
after  it  is  formed;  and  yet  this  change  from  liquid  to  gas  requires 
537  calories  to  each  gram  of  water.  The  latent  heat  of  vapori- 
zation of  water  is,  therefore,  537  calories. 

When  steam  condenses  it  gives  off  this  heat.  In  this  phe- 
nomenon lies  the  explanation  of  the  fact  that  a  Russian  bath 
gives  a  great  intensity  of  effect,  since  much  of  the  steam  con- 
denses, the  water  particles  remaining  suspended  in  the  air  of 
the  room  as  a  thick  fog.  For  every  gram  of  steam  that  thus 
condenses,  537  calories  of  heat  are  liberated.  The  intensity  of 
burns  produced  by  the  condensing  of  steam  directly  on  the  skin 
surface  is  readily  understood  when  this  fact  is  kept  in  mind. 
The  marked  cooling  effects  of  the  evaporating  wet  sheet  pack, 
or  hot  and  cold  sponging,  are  due  to  the  large  amounts  of  heat 
abstracted  from  the  body  by  the  process  of  evaporation. 

With  all  these  facts  before  one,  it  is  apparent  that  the  great 
value  of  water  as  a  thermic  agent  lies  in  its  exceedingly  high 
specific  and  latent  heat  coefficients. 

Specific  heat  refers  to  the  amount  of  heat  concerned  in  the 
temperature  changes  of  matter  within  a  single  state. 

Latent  heat  refers  to  the  amount  of  heat  concerned  in  the 
change  of  matter  from  one  state  to  another  without  any  change  i>i 
temperature. 

2.  Temperature-Conducting  Capacity  of  Water  —  Thermic 
Stimuli.  It  might,  on  first  thought,  seem  that  a  thermic  stim- 
ulus is  identical  with  the  communicating  of  heat.  It,  however, 
does  not  depend  upon  the  amount  of  heat  communicated  to 
or  absorbed  from  the  body,  but  rather  upon  the  impression 


MECHANICAL  STIMULI  23 

made  upon  the  nerves.  In  this  respect  the  temperature  of  the 
body,  or  rather,  that  of  the  skin,  may  be  said  to  be  the  zero  of 
the  temperature  sense.  Water  of  a  temperature  above  this, 
creates  an  impression  of  heat,  while  water  below  this  temper- 
ature gives  a  sensation  of  cold.  A  brief  application  of  ice  may 
give  a  sensation  of  cold  as  intense  as  one  of  longer  duration. 
On  the  contrary,  to  abstract  heat  from  the  body  to  any  appre- 
ciable extent,  the  application  must  be  more  or  less  prolonged. 

These  thermic  stimuli  are  of  the  greatest  value  in  hydrother- 
apy;  we  may  say,  equally  so  with  the  actual  transfer  of  heat. 
Here,  also,  the  thermic  capacity  of  water  makes  it  of  inestim- 
able value.  '  The  temperature -conducting  capacity  of  water 
is  twenty-seven  times  greater  than  that  of  air.  Water  conveys 
to  the  skin  much  stronger  thermic  impressions  than  does  air  at 
the  same  temperature,  a  fact  easily  discovered  in  exchanging  a 
room  temperature  at  75°  F.  for  a  tub  bath  at  the  same  tem- 
perature. ' ' 

And  again,  the  accuracy  with  which  we  may  regulate  the 
temperature  of  hydriatic  applications  and  so  gauge  the  thermic 
impressions  as  well  as  the  heat  communicated  or  absorbed, 
makes  it  doubly  convenient  and  valuable. 

3.  Perfect  Fluidity  of  Water — Mechanical  Stimuli.  The  con- 
venience with  which  water  lends  itself  to  the  application  of 
various  mechanical  stimuli  is  due  to  its  most  apparent  physi- 
cal property— fluidity.  Because  of  this  perfect  fluidity,  its 
application  can  be  controlled  to  a  nicety  not  possible  with  other 
agents.  With  the  proper  appliances,  the  amount  and  temper- 
ature can  be  accurately  gauged.  The  size,  form,  character,  and 
pressure  of  douches,  sprays,  and  pours  can  be  varied  to  suit  the 
varying  needs  of  a  great  variety  of  cases.  It  is  these  four  fac- 
tors that  govern  the  mechanical  effect  in  the  class  of  treat- 
ments mentioned.  Water  may  be  applied  under  very  great 
pressure,  thus  enhancing  the  thermic  effects,  or  it  may  be 
applied  with  little  or  no  pressure. 

Not  only  may  water  itself  be  used  to  apply  percussion,  but 
its  application  may  be  advantageously  combined  with  percussion 
and  friction  from  other  sources,  as  in  the  wet  hand  rub  or  cold 

1     Baruch— Principles  and  Practice  of  Hydrotherapy,  p.  31. 


t4  PROPERTIES  OF  WATER 

mitten  friction.  In  this  case  it  is  the  bare  hand  or  rough  mit- 
ten that  is  the  chief  source  of  friction.  The  Brand  or  cold  rub- 
bing bath  is  another  example  of  this  combination  of  mechanical 
and  thermic  stimuli,  each  enhancing- each.  It  must  not  be  sup- 
posed, however,  that  the  marked  effect  of  this  form  of  bath  is 
due  merely  to  a  combination  of  the  thermic  and  mechanical 
stimuli.  It  is  necessary  that  water  be  used.  Apropos  of  this 
question,  we  quote  the  following  from  Baruch:  "We  would 
again  insist  upon  the  fact  that  neither  in  typhoid  nor  in  cardiac 
inadequacy,  can  these  effects,  or  anything  like  them,  be  pro- 
duced by  cold  alone  (for  that  has  been  thoroughly  tried  in  both 
cases),  by  the  temporary  application  of  water  alone,  of  what- 
ever temperature,  or  by  either  dry  saline  or  gaseous  or  mech- 
anical irritants.  It  is  absolutely  necessary  that,  not  merely 
cold,  but  cold  water  should  be  used,  that  the  surface  should  be 
literally  rubbed  with  this  for  a  considerable  length  of  time."  -' 

The  same  may  be  said  of  the  cold  mitten  friction.  The  aston- 
ishing results  of  this  procedure  can  be  obtained,  neither  by  the 
application  of  cold  alone  nor  by  friction  with  the  dry  mitt.  It 
is  only  by  vigorous  rubbing  with  the  mitt,  dipped  in  cold  water, 
that  the  maximum  effects  are  produced. 

4.  Solvent  and  Chemical  Properties.  That  these  properties 
are  of  less  importance  than  the  preceding  will  be  granted  by 
those  familiar  with  hydriatic  measures.  The  solvent  properties 
of  water  are  utilized  in  the  shampoo,  enema,  etc.  Its  value  as 
a  solvent  in  the  processes  of  osmosis  and  dialysis  are  likewise 
made  use  of  in  hypodermoclysis  and  saline  enemata.  As  a 
means  of  combining  thermic  and  chemical  stimuli,  it  is  used  as 
a  solvent  in  the  Xauheim  or  effervescent  bath,  saline  baths,  etc. 

Internal  Hydrotherapy.  Going  a  little  further  from  the  physi- 
cal into  the  chemical  activities,  and  almost  outside  of  tin- 
range  of  hydrotherapy,  unless  it  be  in  water-drinking,  we  may 
consider  water  in  its  relation  to  the  nutritive  and  metabolic  pro- 
cesses of  the  human  body.  It  is  the  medium  of  all  commerce 
and  exchange  in  the  carrying  of  nutrition  to  the  tissues,  and 
wastes  from  them  to  the  excretory  organs.  It  constitutes  75 
per  cent  of  the  body  weight.  Without  it  life  would  be  impos- 

2    Baruch— Principles  and  Practice  of  Hydrotherapy.  p.  12. 


WATER  IN  THREE  STATES  25 

sible.  Not  only  is  it  concerned  in  the  mere  physical  inter- 
change of  nutrient  and  waste  substances,  but  it  is  actually 
necessary  in  by  far  the  greater  number  of  all  chemical  changes 
which  these  substances  undergo.  Many  body  wastes  are  but 
sparingly  soluble,  and  for  this  reason  require  large  amounts  of 
water  to  hold  them  in  solution.  The  flushing  of  the  system 
consequent  on  free  water-drinking  is,  therefore,  one  of  the 
greatest  of  all  aids  to  elimination. 3 

The  popular  belief  that  particular  virtue  resides  in  the  min- 
eral constituents  of  water  used  for  hydrotherapeutic  purposes  is 
almost  wholly  erroneous.  This  is  rarely  the  case  and  is  con- 
fined to  a  very  few  procedures  such  as  the  Nauheim  bath  above 
mentioned.  The  treatment  of  rheumatism  and  obesity  at  vari- 
ous hot  springs  derives  but  little  advantage  from  minerals  pres- 
ent in  the  water  (unless  it  be  that  "  faith  "  in  these  induces  the 
patient  to  drink  more  water  than  usual).  The  results  are  due 
to  the  thermic  effects  of  the  hot  water,  combined  with  regulation 
of  diet  and  copious  water-drinking.  Balneology — the  use  of 
mineral  waters  in  the  treatment  of  disease,  therefore,  adds  little 
or  nothing  to  the  science  of  hydrotherapy. 

5.  Use  of  Water  in  Solid,  Liquid,  and  Gaseous  States.  No 
other  substance,  capable  of  such  diversified  utility  as  water, 
exists  in  all  the  three  states  of  matter  in  such  a  short  range 
of  temperature.  The  change  from  the  solid  through  the  liquid 
to  the  gaseous  state  is  accomplished  in  a  range  of  180°  F. 
(100°  C.).  Not  only  is  this  true,  but  it  also  changes  readily 
from  one  form  to  another.  It  is  possible  to  apply  water  to  the 
body  in  any  of  these  forms;  even  the  application  of  the  two  ex- 
treme forms — ice  and  steam — is  of  practical  utility.  The  ice 
bag  is  an  indispensable  adjunct  to  a  great  variety  of  treatments. 
The  ice  rub  has  also  been  mentioned.  The  use  of  Russian  and 
similar  vapor  baths  is  well  known.  The  steam  douche  has  also 
acquired  some  degree  of  reputation  as  a  therapeutic  agent  in 
certain  conditions.  This  practicability  of  employing  water  in  all 
three,  states  of  matter  and  its  ready  change  from  one  to  another 
within  a  comparatively  short  range  of  temperature,  greatly 
enhances  its  utility  as  a  therapeutic  agent. 


3    See  Chapter  XI,  Hawk's  observations. 


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CHAPTER   II 

PRINCIPLES  OF  EFFECTS  AND  THERAPY 

THE  basic  principles  of  hydrotherapy  are  found  chiefly  in  an 
explanation  of  the  effects  of  heat  and  cold.  Viewed  in 
this  light,  the  science  is  that  of  thermotherapy.  Effects  similar 
to  those  produced  by  thermic  impressions  can  be  obtained  by 
sunlight,  friction,  percussion,  and  in  fact,  all  physiologic  agents. 
This  is  most  notably  true  of  light,  many  of  the  physiologic 
effects  of  which  run  parallel  with  those  of  hydrotherapy.  In 
fact,  thermic  and  actinic  energies  are  so  closely  related  that  they 
overlap  each  other  in  the  visible  spectrum  (Fig.  J.).  From  the 
lowest  limit  of  the  scale  of  energies,  up  through  electric  energy, 
heat,  light,  and  actinic  rays  to  radium  emanations  and  the 
X-ray,  there  is  laid  out  before  the  physician  a  greater  supply 
of  efficient  curative  means  than  can  be  found  anywhere  else  in 
the  whole  realm  of  therapeutics. 

THERAPY   FROM  WITHIN 

Those  agents  which,  by  their  toxic  action,  arouse  the  body  to 
resist  their  intrusion,  can  not  be  classed  as  physiologic  means. 
They  excite  abnormal  and  unusual  activities  which  are  largely 
directed  against  the  toxic  agent  itself,  rather  than  heightening 
the  normal  activities  which  keep  the  body  in  health  and  repel 
the  onset  of  morbid  processes.  Merely  to  relieve  temporarily  a 
distressing  condition,  without  enabling  the  body  itself  to  over- 
come that  condition,  is  doing  no  permanent  good.  The  sick  can 
not  always  be  applying  special  means.  After  recovery,  they 
must  depend  upon  the  natural  surroundings  and  ordinary  agen- 
cies which  keep  the  body  in  health.  For  example,  to  relieve 
pain  by  cocaine,  an  ice  bag,  pressure,  or  a  fomentation  is  pro- 

(27) 


t8  PRINCIPLES  OF  EFFECTS  AND  THERAPY 

ductive  of  no  lasting  good,  unless  that  cocaine,  ice  bag,  press- 
ure, or  fomentation  causes  the  body  to  overcome  the  condition 
producing-  the  pain;  and  its  repeated  application  brings  about 
such  a  change  that  the  pain  (or  diseased  condition)  does  not 
reappear  after  the  curative  agent  is  withdrawn.  The  body 
must  be  made  to  ' '  cure  ' '  itself.  The  restorative  power  lies  in 
nature.  The  natural  God-given  forces  must  be  rejuvenated. 
The  power  from  without  must  produce  or  arouse  power  from 
within. 

WARM-  AND  COLD-BLOODED  ANIMALS 

The  reason  that  thermic  applications  and  impressions  are  so 
powerful  in  arousing  body  functions  lies  in  the  fact  that  life 
activities  are  carried  on  only  within  a  certain  limited  range  of 
temperature.  With  regard  to  body  temperature,  there  are  two 
general  classes  of  animals,  viz.,  the  warm-  and  the  cold-blooded. 

The  temperature  of  so-called  ' '  cold-blooded  ' '  (poikilother- 
mic)  animals  rises  and  falls  with  their  surroundings.  The 
organism  is  not  injured  by  comparatively  wide  variations.  The 
frog,  for  example,  is  lively  in  water  at  70°  F.,  and  sluggish 
in  water  at  45°  F.,  but  it  nevertheless  lives  and  remains  nor- 
mal in  either.  These  variations  do  not  seriously  depress  vital 
activities.  The  organism  is  able  to  withstand  such  radical 
changes  in  the  temperature  of  its  blood  and  body  generally, 
without  this  change  being  inimical  to  its  life.  The  body  tem- 
perature of  these  animals  remains  slightly  above  that  of  the 
cold  water  they  may  be  in  and  slightly  below  that  of  warm 
water.  Cold-blooded  animals  are  principally  aquatic  and 
amphibian. 

Certain  other  animals  maintain  a  constant  temperature  under 
varying  conditions.  The  surrounding  air,  whether  hot  or  cold, 
does  not  materially  alter  their  body  temperature.  '  The  heat 
mechanism  is  so  nicely  adjusted  that  more  heat  is  produced 
when  the  surrounding  medium  is  cold,  and  less  when  the  air  or 
other  medium  is  hot.  This  class  of  animals  is  called  "warm- 
blooded "  (homeothermic)  because  of  the  constant  temperature 
at  which  their  blood  is  kept.  Arterial  blood  is  slightly  warmer 
than  venous.  The  ordinary  limits  for  man  are  about  101° — 
103°  F. 


INTRINSIC  EFFECTS  29 

Organs  of  constant  activity,  such  as  the  heart,  liver,  and 
brain  have  a  temperature  2° — 4°  higher  than  the  average  of  the 
blood  stream.  At  ordinary  room  temperature,  the  uncovered 
skin  has  a  temperature  of  from  92° — 95°  F.  This  fact  is  of 
importance  in  the  administration  of  neutral  baths.  The  water 
should  be  1°  or  2°  higher  than  that  of  the  general  skin  tempera- 
ture. This  secures  a  full  sedation  by  adding  a  slightly  relaxing 
effect.  As  noted  above,  the  internal  temperature  of  warm- 
blooded animals  is  comparatively  a  fixed  point,  or  varies  within 
only  very  narrow  limits,  not  more  than  one  degree  in  health. 
Any  radical  or  prolonged  departure  from  this  fixed  point  (98.6° 
F.  by  mouth)  interferes  with  vital  functions. 

INTRINSIC  EFFECTS 

When  the  body  becomes  thoroughly  chilled,  as  by  a  long  ride 
in  the  cold,  the  pulse  and  respiration  are  slowed,  the  circulation 
is  less  rapid,  the  nerves  benumbed,  the  muscles  respond  slug- 
gishly and  clumsily,  the  finer  skilled  movements  are  impos- 
sible, digestion  is  retarded,  the  body  temperature  is  lowered. 
Cold  is,  therefore,  in  itself,  a  vital  depressant,  i.  e.,  it  retards 
vital  processes.  This  is  its  intrinsic  effect.  Kellogg  records 
an  experiment  in  which  immersion  of  the  body  in  water  at 
55°  F.  for  ten  minutes  reduced  the  pulse  rate  from  seventy-six 
to  fifty  per  minute.  Another,  in  which  twenty  minutes  in 
water  at  45°  F.,  the  patient  being  rubbed  continuously,  re- 
duced the  pulse  rate  from  eighty  to  fifty-eight.  Both  experi- 
ments were  upon  healthy  persons.  In  another  experiment  ex- 
posure to  cold  showed  tactile  sensibility  decreased.  Before  the 
exposure  the  points  of  an  esthesiometer  were  detected  as  two 
separate  points  at  a  minimum  separation  of  2  mm.  After  five 
minutes  immersion  in  water  at  40°  F.,  the  minimum  distance 
was  increased  to  6  mm.  Another,  in  which  five  minutes  in 
water  at  68.4°  F.,  reduced  the  body  temperature  0.8°  F.  These 
data  serve  to  make  definite,  facts  with  which  we  are  acquainted 
in  a  general  way  only. 

It  will  be  seen  from  this  that  an  overactive  process  may  be 
retarded  and  brought  back  toward  the  normal  by  an  application 
of  cold,  continued  until  its  intrinsic  effects  are  manifest.  The 


SO  PRINCIPLES  OF  EFFECTS  AND  THERAPY 

longer  the  duration  of  the  cold  application,  the  greater  its 
effect.  The  same  is  true  of  the  degree  of  cold.  The  lower  the 
temperature,  the  more  pronounced  the  effects. 

While  cold  retards,  heat  stimulates  vital  activities.  We  know 
what  it  is  to  experience  the  vivifying  effects  of  the  warmth  from 
a  fire  or  sunlight  after  being  in  very  cold  air  for  some  time. 
The  circulation  is  quickened;  the  heart  beats  faster;  respiration 
is  more  rapid;  nerve  sensibility  is  heightened;  muscular  action 
is  quicker,  more  certain,  and  precise;  and  digestion  proceeds 
more  rapidly.  In  watching  the  activity  of  the  white  blood  cell 
under  the  microscope,  the  stage  must  be  kept  warm  or  the 
movements  will  cease.  The  amoeba,  paramoecium,  and  other 
one-celled  animals  exhibit  their  peculiar  movements  only  in  the 
presence  of  a  certain  amount  of  heat.  When  cold,  their  move- 
ments cease  entirely.  Cold,  per  se,  decreases  oxidation  and 
metabolic  activities;  heat  increases  the  oxidizing  capacity  of  the 
tissues  and  metabolic  activities  are  hastened. 

When  the  body  is  overheated  its  functions  are  abnormally 
increased  and,  if  long  continued,  permanent  injury  may  result. 
When  heated  only  to  a  slight  degree,  however,  sluggish  activi- 
ties are  whipped  up  and,  if  the  applications  of  heat  are  repeated 
at  intervals,  the  retarded  functions  tend  to  return  to  normal. 

REACTION 

The  most  interesting  and  phenomenal  results  of  hydrotherapy 
are  due  to  that  complex  process — reaction,  i.  e.,  the  part  which 
the  body  itself  takes  in  its  own  recuperation  and  healing.  This 
interesting  phenomenon,  in  its  entirety,  is  observed  only  in 
homeothermic  animals.  Cold-blooded  animals,  instead  of  re- 
acting to  their  external  medium,  are  subject  to  the  vicissitudes 
of  their  environment.  On  the  contrary,  warm-blooded  animals 
maintain  more  or  less  uniformity  of  function  because  of  the  per- 
fect control  exercised  over  vital  processes  by  the  nervous  system. 
This  control  is  more  highly  developed  and  complicated  than  in 
poikilothermic  animals. 

We  have  seen  that  the  influence  of  cold  is  to  depress  vital 
activities;  that  is,  if  continued  long  enough,  its  intrinsic  effect 
is  manifest  in  depression.  But  let  us  notice  the  effects  of  a 


REACTION  SI 

£r/</ application  of  cold.  A  plunge  into  cold  water  increases 
the  pulse  rate  and  force,  the  skin  becomes  reddened  because  of 
a  quickened  peripheral  circulation,  and  the  respiration  is  deeper. 
The  muscles  are  energized  so  that  their  capacity  for  work  is 
increased.  These  heightened  activities  continue  for  a  time, 
gradually  returning  to  normal.  This  is  reaction, — which  may  be 
defined  as  a  group  or  series  of  changes  inaugurated  by  the  body 
because  of  some  disturbing  external  agent.  More  briefly,  it  is 
the  response  of  the  organism  to  an  external  agent. 

Rationale  of  Reaction.  The  explanation  of  these  tonic  and 
stimulating  effects  lies  in  the  recognition  of  cold  by  the  body 
as  an  agent  which  will  depress  its  functions.  Even  though 
the  contact  be  too  brief  to  actually  bring  about  this  result,  it 
immediately  increases  its  activities  in  order  to  counteract  the 
anticipated  depression.  The  body  tends  to  resist  or  overbalance 
attempts  to  alter  its  temperature.  In  doing  so  it  is  said  to  react 
against  this  change,  or  attempted  change.  Cold,  in  and  of  it- 
self, causes  depression.  But  the  attempt  on  the  part  of  the 
body  to  resist  this  depression  results  in  heightened  activity. 
This  is  spoken  of  as  the  reaction  or  reactionary  effect.  It  is 
always  the  opposite  of  the  intrinsic  effect.  Some  very  common 
examples  of  this  will  serve  to  illustrate  the  principle.  An  ice 
bag  applied  over  the  heart  for  five  minutes  slows  the  pulse  rate; 
while  slapping  the  chest  with  a  cold  wet  towel,  or  the  brief 
application  of  a  cold  douche  to  the  chest,  increases  both  the 
pulse  and  respiration  rate.  A  long  cold  application,  as  a  cold 
tub  bath,  lowers  the  body  temperature,  while  a  short  cold  appli- 
cation, as  a  cold  plunge  or  cold  douche,  soon  results  in  an 
increase  of  body  temperature. 

If  the  external  cause  is  long  continued,  the  reaction  may  not 
be  apparent,  may  be  lost,  or  obscured  by  the  intrinsic  effect.1 
The  body  reacts  or  attempts  to  react  to  even  prolonged  applica- 


1  In  discussing  these  two  classes  of  effects,  intrinsic  and  reactionary,  some  writers 
use  the  term  "  primary  "  as  synonymous  with  intrinsic,  and  the  term  "  secondary  "  as  syn- 
onymous with  reaction.  Since  the  intrinsic  effect  of  cold  is  neither  primary  in  point  of 
time,  nor  in  all  cases  primary  in  importance,  the  term  leads  to  cjnfusion.  The  same 
may  be  said  of  the  expression  "secondary."  The  reaction  often  appears  before  the 
intrinsic  depressant  effect  of  the  cold  becomes  manifest  and  so  can  not  be  said  to  be  sec- 
ondary as  far  as  time  is  concerned.  Also,  if  from  a  certain  application  a  reaction  is 
desired,  then  the  reaction  can  not  be  said  to  be  secondary  in  importance.  For  these  rea- 
sons we  object  to  the  terms  as  demanding  different  definitions  under  different  circum- 
stances of  use.  They  must,  therefore,  prove  confusing. 


St  PRINCIPLES  OF  EFFECTS  AND  THERAPY 

tions  of  cold,  so  that  what  is  seen  as  a  result  of  these  long 
applications  is  really  a  mixture  of  the  intrinsic  and  reactionary 
effects.  As  to  which  shall  predominate  depends  upon  the 
intensity  and  duration  of  the  application.  With  the  more  pro- 
longed applications,  the  reaction  is  suppressed  or  obscured; 
while  in  those  of  intermediate  duration,  we  often  see  as  much 
of  one  as  of  the  other. 

With  heat,  as  used  in  actual  practice,  we  observe  its  intrinsic 
effects  when  the  hot  application  is  short,  i.  <?.,  of  brief  duration. 
The  first  effect  of  heat  is  that  of  a  stimulant  and  tonic;  but,  if 
long  continued,  depression  results.  This  depression  is,  by 
some,  termed  "a  reaction."  Baruch  objects  to  this  term  as 
applied  to  heat.  If  we  define  reaction  as  the  vital  response  to 
an  external  force,  or  the  attempt  on  the  part  of  the  organism  to 
counteract  an  external  agent,  we  can  see  no  great  objection  to 
the  term,  or  to  saying  that  the  reaction  to  heat  is  of  an  atonic 
nature. 


Fig.  4.    Diagram  illustrating  the  time  factor  in  the  obtaining  of 
intrinsic  and  reactionary  effects. 


The  accompanying  diagram  (Fig.  4.)  illustrates  the  relation 
existing  between  the  duration  of  the  application  and  the  obtain- 
ing of  intrinsic  and  reactionary  effects.  The  thick  ends  of  the 
wedges"  indicate  prolonged  applications;  the  thin  ends,  brief 
applications.  Intrinsic  effects  are  shown  at  the  left  and  reac- 
tions at  the  right. 

Tonic  effects  are  obtained  from  the:  Intrinsic  effects  of  heat 
(short);  reaction  to  cold  (short). 

Retarding  and  depressant  effects  are  obtained  from  the:  Re- 
action to  heat  (long);  intrinsic  effects  of  cold  (long). 


PHASES  OF  REACTION  33 

It  must  not  be  concluded  from  the  above  grouping1  that  the 
depressant  effects  of  a  long  cold  application  (intrinsic)  and 
those  of  a  long  hot  application  (reaction)  are  identical  in  nature. 
The  depression  is  manifest  in  different  ways.  With  cold  the 
depression  is  in  the  nature  of  a  simple  retardation  of  vital  func- 
tions, whereas  with  the  heat  the  depression  is  manifest  chiefly 
in  the  nervous  and  muscular  systems, 4  and  is  perhaps  best  de- 
scribed as  atonic.  That  this  is  largely  a  nervous  phenomenon 
is  apparent  from  the  fact  that  a  vigorous  cold  treatment  follow- 
ing prolonged  heat  often  quickly  restores  the  patient  to  a  nor- 
mal condition. 

Abrams  2  makes  the  following'  statement :  ' '  Respecting-  the 
physiologic  effects  of  heat,  it  suffices  to  say,  that  a  prolonged 
application  of  a  high  temperature  is  primarily  an  excitant,  and 
secondarily  a  depressant;  a  brief  application,  however,  is 
strongly  excitant  and  the  depressing  effects,  if  any,  are  imper- 
ceptible." In  discussing  the  effects  of  thermic  stimuli  (on 
secretion)  Pope3  says,  "  In  general  terms  it  may  be  stated  that 
brief  applications  of  thermic  stimuli,  whether  hot  or  cold,  stimu- 
late secretion,  differing  in  degree  rather  than  in  toto;  long-con- 
tinued' applications  depress . ' ' 

Phases  of  Reaction.  There  are  two  important  phases  of 
reaction,  viz.,  the  circulatory  and  the  nervous.  The" circulatory 
is  most  apparent  and  is  that  by  which  we  judge  of  the  com- 
pleteness of  reaction.  The  skin  should  become  ruddy  and 
warm.  The  patient  feels  a  warm  glow  over  the  entire  skin 
surface.  There  should  be  nothing  of  stasis,  no  cyanosis,  or 
goose  flesh.  The  skin  should  be  smooth,  soft,  and  pliable. 
The  nervous  reaction  is  appreciated  not  only  by  the  patient  but 
by  the  observer.  The  dull,  listless  appearance  of  the  eye  and 
countenance  generally,  gives  way  to  a  decided  brightening.  If 
there  is  delirium  or  stupor,  as  in  typhoid,  pneumonia,  etc.,  it 
may  be  replaced  by  quiet  sleep.  In  fact,  the  salutary  effects 
are  visible  in  all  the  nervous  functions  of  the  body.  With  a 
neurasthenic  patient  the  feeling  of  languor,  restlessness  and 

2  Spondylotherapy,  p.  175. 

3  Hydrotherapy,  p.  35. 

4  Metabolic  changes  are  hastened  by  prolonged  heat. 

3 


34  PRINCIPLES  OF  EFFECTS  AND  THERAPY 

weight  in  the  abdomen  is  replaced  by  that  of  vigor  and  exhil- 
aration. Another  phase  of  reaction  is  that  termed  thermic. 
It  is  the  response  of  the  heat  mechanism  to  stimulation.  It  is 
of  less  practical  importance  since  it  can  not  be  conveniently 
utilized  in  judging-  of  the  completeness  of  reaction. 

TYPES  AND  DEGREES  OF  REACTION 

Suppressed  Reaction.  It  is  often  desirable  to  suppress  or 
limit  the  reaction  arising-  from  some  application.  This  is  espec- 
ially true  with  long-  cold  applications  which  are  designed  to 
delay  vital  activities  or  reduce  fever.  Of  course,  the  body 
attempts  to  react  to  all  such  measures,  as  has  been  mentioned. 
The  reaction  may  be  limited,  e.  g.,  by  a  cold  application  such 
as  an  ice  bag-  to  a  part.  The  nervous  excitability  is  lessened 
by  the  continuous  and  severe  cold,  so  that  the  phenomena  of 
reaction  do  not  appear  in  their  .entirety  and  completeness.  In 
the  case  of  a  Brand  bath,  the  exciting-  stage  soon  gives  way  to 
a  slower  heart  beat,  slower  and  deeper  respiration,  etc.,  by 
reason  of  the  continuance  of  the  cold.  In  general,  the  suppres- 
sion of  the  reaction  depends  upon  the  intensity  of  the  cold  and 
its  duration,  being  greater  with  the  lower  temperatures  and  with 
the  prolonging  of  the  application. 

Repeated  Reaction.  In  the  giving  of  alternate  hot  and  cold 
treatments,  the  body  is  called  upon  to  react  several  times.  After 
two  or  three  applications,  the  reactions  are  less  complete.  The 
oscillatory  changes  occurring  in  the  blood-vessels  become  less 
and  less  in  amplitude  after  each  succeeding  application.  In 
order  to  produce  complete  reactions  where  the  applications  are 
repeated,  it  is  necessary  to  increase  the  intensity  of  the  stimu- 
lus. This  may  be  done  in  the  case  of  alternate  hot  and  cold  by 
using  a  higher  temperature  for  the  hot  and  a  lower  temperature 
for  the  cold,  or  by  adding  mechanical  stimuli. 

Incomplete  Reaction.  Applications  not  properly  suited  to 
the  reactive  ability  of  a  patient  will  result  in  an  incomplete 
reaction.  Should  this  occur,  the  patient  experiencies  quite 
unpleasant  symptoms,  such  as  chilliness,  shivering,  cold  feet,  a 
feeling  of  fulness  in  the  head,  and  even  faintness  and  nausea. 


CONDITIONS  INFLUENCING  REACTION  35 

These  are  due  mostly  to  the  internal  congestion  which  has  not 
been  relieved  or  has  been  made  more  intense. 

CONDITIONS  INFLUENCING  REACTION 

Age  and  Vitality  of  the  Patient.  In  either  extreme  of  life  the 
ability  to  react  is  quite  limited.  Neither  infants  nor  aged  per- 
sons bear  cold  treatment  well.  We  have  treated  persons  in 
advanced  life  who  were  utterly  unable  to  react  to  even  cool 
water  as  applied  by  the  wet  hand  rub,  and  who  invariably 
chilled  after  a  cold  mitten  friction. 

In  certain  diseases  or  states  the  vitality  is  so  reduced  as  to 
render  reaction  extremely  difficult.  This  is  true  of  nearly  all 
those  diseases  which  produce  a  profound  asthenia.  In  anemia 
and  extreme  emaciation  the  same  conditions  prevail.  In  all 
such  cases  it  is  necessary  to  thoroughly  warm  the  body  previous 
to  the  cold  application  and  give  vigorous  friction  during  and 
following  the  treatment.  Even  these  means  will  not  always 
insure  a  reaction. 

Exercise,  sufficient  to  warm  the  body,  promotes  reaction. 
This  is  true  whether  taken  before  or  after  the  treatment.  It 
quickens  the  circulation  and  brings  the  blood  to  the  surface. 
•Body  heat  is  increased  so  that  the  surface  blood-vessels  become 
dilated  in  order  to  increase  heat  elimination.'  Fatigue  is  not 
conducive  to  completeness  of  reaction.  In  case  it  is  necessary 
to  treat  persons  who  are  fatigued,  a  short  hot  application  should 
be  given  first,  quickly  followed  by  some  short  but  very  vigor- 
ous cold  treatment,  accompanied  by  friction  or  percussion. 

The  Warmth  of  the  Body.  When  the  body  is  warm,  reaction 
appears  promptly.  The  internal  heat  of  the  body  may  be  ever 
so  much  and  yet  reaction  be  impossible,  if  the  skin  is  cold  and 
clammy,  pale,  cyanotic,  or  goose  flesh  in  appearance.  The 
skin  should  be  warm  and,  if  possible,  ruddy  before  cold  appli- 
cations are  used.  In  case  it  is  not,  some  sort  of  hot  treatment 
should  be  used  first,  in  order  to  draw  the  blood  to  the  skin. 
The  air  of  the  room  in  which  the  patient  is  treated  should  be 
warm  and  he  should  remain  in  a  warm  room  after  treatment 
until  reaction  is  complete.  It  may  be  necessary  to  give  a 
drink  of  hot  water  in  order  to  warm  the  body.  More  essential 


36  PRINCIPLES  OF  EFFECTS  AND  THERAPY 

than  all  of  these  is  the  warmth  of  the  feet.  It  is  impossible  to 
secure  full  reaction  or  the  best  possible  results,  if  the  feet  are 
cold.  It  should,  therefore,  be  a  general  rule  that  the  feet 
should  be  warmed  by  a  hot  foot  bath  or  alternate  hot  and  cold 
foot  bath  or  hot  foot  pack,  previous  to  any  and  all  treatment. 
In  the  giving  of  even  an  enema,  this  is  necessary.  After  treat- 
ment it  may  be  necessary  to  provide  the  patient  with  additional 
covering-,  either  in  the  form  of  bedding  or  clothing,  in  order  to 
secure  full  reaction. 

Psychic  Attitude.  It  is  difficult  to  produce  complete  reaction 
in  a  patient  that  dislikes  the  measures  used.  That  the  mind  does 
exercise  an  inhibitory  influence  over  body  functions  can  not  be 
doubted  by  those  whose  practice  brings  them  in  contact  with 
profound  neurasthenia.  Those  under  great  mental  strain, 
worry,  or  anxiety,  react  poorly. 

Character  of  Treatment  and  Mode  of  Application.  In  all 
cases  where  reaction  is  likely  to  be  tardy,  the  cold  treatment 
should  be  preceded  by  a  hot  treatment.  In  ordinary  cases  the 
hot  application  should  exceed  in  duration  the  cold  application. 
It  should  thoroughly  warm  the  body  and  make  the  cold  a  wel- 
come change.  The  reaction  is  more  prompt  in  its  appearance 
if  extreme  cold  is  used  and  accompanied  by  friction  or  percus- 
sion. The  colder  the  water,  the  greater  the  reaction.  The 
cold  treatment  should  be  given  quickly.  The  treating  of  one 
part  at  a  time  favors  the  quick  appearance  of  the  reaction. 
The  larger  an  application  or  more  general  the  surface  treated, 
the  less  promptly  will  the  reaction  appear.  Friction  with  the 
dry  hand  or  a  rough  towel,  following  the  drying,  enhances 
the  reaction.  Percussion  has  the  same  effect.  The  drying 
from  sprays  and  general  applications  of  water  should  be  done 
as  quickly  and  as  thoroughly  as  possible.  If  moisture  is  left  on 
the  surface,  the  resulting  evaporation  cools  the  body  and  re- 
-action  is  delayed.  The  patient  should  be  dried  in  a  warm 
room  near  the  place  where  the  last  application  of  water  was 
made.  To  properly  shape  circumstances  so  as  to  favor  re- 
action, requires  much  care  and  forethought  on  the  part  of  the 
attendant  nurse.  A  little  carelessness  may  undo  much  or  all 
of  the  benefit  which  should  accrue  from  a  given  treatment. 


NAMES  OF  TEMPERATURES  37 

Test  of  Reactive  Ability.  Ability  to  react  to  cold  applica- 
tions varies  with  the  climate  of  usual  residence,  state  of  health, 
occupation,  and  habits  of  the  patient.  As  to  the  reactive  capacity 
little  can  be  determined  by  questioning  the  patient.  Often 
those  who  say  they  are  unable  to  take  cold  baths  react  as  well 
or  better  than  those  who  affirm  their  ability  to  react.  What  one 
calls  very  cold  another  regards  as  only  cool.  Some  persons 
consider  that  they  have  been  taking"  cold  baths  when  bathing 
in  water  at  90° — 95°  F.  The  response  of  a  patient  with  anemia 
is  usually  in  direct  proportion  to  the  degree  of  anemia.  The 
state  of  the  vasomotors  and  the  readiness  with  which  they  react 
to  mechanical  stimuli  serve  as  a  rough  test  of  the  ability  to  re- 
spond to  cold  treatment.  This  test  is  mentioned  by  nearly  all 
writers  on  hydrotherapy.  Baruch0  makes  the  following  state- 
ment:— 

' '  I  have  found  that  the  response  of  the  cutaneous  circulation 
to  mechanical  excitation  furnishes  an  index  to  the  probable  re- 
active capacity  of  the  patient.  Passing  the  back  of  the  nail  of 
the  index  finger  rapidly  but  gently  across  the  abdomen,  and 
increasing  the  pressure  of  the  nail  with  a  second  stroke  parallel 
to  the  first,  induces  a  more  or  less  deep  reddening  of  the  irri- 
tated skin.  The  rapidity  with  which  the  red  line  develops  after 
the  nail  is  removed,  and  the  pressure  required  to  produce  it, 
afford  the  trained  eye  a  crude,  but  fairly  correct,  test  of  the 
patient's  reactive  capacity.  By  applying  this  test  frequently 
before  each  procedure,  one  may  readily  train  the  appreciation 
of  this  test  and  thus  avoid  the  necessity  of  slow  development 
of  the  reaction  by  gradual  increase  of  the  intensity  of  the  treat- 
ment which  the  author  adopts  in  most  cases . ' ' 

COMMON  NAMES  OF  TEMPERATURES 

Heat  and  cold  are  relative,  not  absolute,  terms  and  must 
needs  be  defined.  This  can  not  be  done  with  accuracy,  since 
patients  differ  in  their  toleration  of  heat  and  cold.  What  one 
designates  as  very  cold  may  be  only  cool  to  another.  The  ex- 
tent of  skin  surface  exposed  to  thermic  stimulation  also  makes 
a  difference  in  the  degree  of  the  temperature  impression  re- 

5    Hydrotherapy,  p.  102. 


38  PRINCIPLES  OF  EFFECTS  AND  THERAPY 

ceived.  For  example,  immersion  of  the  hand  in  water  at  70°  F. 
will  give  an  impression  of  cold;  but,  if  the  entire  body  is 
immersed,  the  water  will  seem  -very  cold.  Again,  a  full  tub 
bath  at  105°  F.  will  seem  very  hot;  while,  if  only  one  hand  is 
immersed,  the  impression  received  is  that  of  only  moderate  heat. 
The  most  satisfactory  way  of  designating  temperatures  is  to 
define  the  limits  in  terms  of  degrees.  The  table  below  has 
been  found  practical.  The  designations  above  neutral  arc 
those  that  would  be  used  for  full  tub  baths;  those  below  neutral 
are  such  as  would  be  used  for  partial  immersion. 

Very  hot  104°  and  above 

Hot    •  100°— 104°  F. 

Warm  (neutral,  94°— 97°)  92°— 100°  F. 

Tepid  80°—  92°  F. 

Cool  70°—  80°  F. 

Cold  55°—  70°  F. 

Very  cold       -  -       32°—  55°  F. 


CHAPTER'  III 
ANATOMY  AND  PHYSIOLOGY  OF  THE  SKIN 

THE  skin  is  the  key-board  of  hydrotherapy.  Comprising"  as 
it  does  such  a  large  variety  of  tissue  elements  in  an  exceed- 
ingly complicated  arrangement  {Plate  /.),  every  part  of  which 
is  directly  or  indirctly  connected  with  the  functions  of  all  other 
parts  of  the  body,  it  is  essential  that  its  more  important  func- 
tions and  their  anatomic  basis  should  be  well  understood.  This 
is  especially  true  of  the  vessels  and  nerves  of  the  skin  through 
which  this  connection  with  the  internal  organs  is  made;  for  by 
these  connections,  the  physician  is  enabled  to  influence  at  will 
the  circulation,  and  to  a  large  extent,  all  the  other  functions  of 
these  organs.  Only  those  points  which  serve  to  explain  the 
practical  applications  of  hydrotherapy  will  be  noticed  here. 

The  epidermal  layer  acts  as  a  protection  to  the  delicate  and 
sensitive  structures  underneath. 

The  dermis  contains  those  structures  with  which  we  are  most 
concerned.  It  is  made  up  of  two  fairly  distinct  layers — the 
pars  papillaris,  upon  which  the  epithelium  rests,  and  the  pars 
reticularis  beneath  the  former  and  lying  next  to  the  panniculus 
adiposis.  The  knob-like  projections  of  the  papillary  layer  are 
of  two  types,  viz.,  those  containing  blood-vessels  (vascular  pa- 
pillae) and  those  containing  nerve  endings  (tactile  papillae). 
Both  layers  of  the  dermis  consist  of  a  reticulum  composed  of 
bundles  of  connective  tissue,  surrounded  by  elastic  fibers. *  For 
the  most  part,  the  fibrous  bundles  lie  parallel  to  the  skin  sur- 
face. Those  fibers  nearer  the  surface  are  finer  and  more 
densely  packed,  producing  a  felt-like  texture,  while  those  of  the 

1     Bohm,  Davidoff,  and  Huber— Text  Book  of  Histology,  p.  382. 

(39) 


40  ANATOMY  AND  PHYSIOLOGY  OF  THE  SKIN 

deeper  layers,  nearer  the  subcutaneous  fat,  are  coarser  and  more 

loosely  arranged. 

MUSCULAR  AND  ELASTIC  TISSUE 
Smooth  muscle  fibers  are  intimately  associated  with  the  elas- 
tic fibers.     The  two  together  constitute  one  of  the  most  impor- 
tant anatomic  arrangements  in  the  skin,  as  we  shall  see  pres- 
ently.    In  many  parts  of  the  skin  the  muscle  fibers  are  present  in 
the  form  of  a  network,  contracting  diagonally. 2     The  muscular 
tissue  exists  mostly  as  the  erectores  pilorum  disposed  in  bundles 
in  connection  with  the  hair  follicles  and  lying  in  an  oblique 
direction  through  the    thickness   of   the    skin.     These    muscle 
bundles  are  surrounded  and  traversed  by  elastic  fibers  so  that 
they  are  enclosed  in  a  dense  network  of  elastic  tissue,  threads 
of  .which  serve  as  tendons  to  connect  the  ends  of  the  muscular 
fasciculi  to  the  connective  tissue  bundles  of  the  corium.3     The 
varied  degrees  of  tension  of  the  skin  are  due  to  the  changes  in 
this  musculo-elastic  mechanism.     Baruch  lays  much  stress  upon 
these  changes  as  being  the  chief  cause  of  alterations  in  the  cuta- 
neous circulation,  which  are  brought  about  by  thermic  impres- 
sions.    Under  medium  temperatures  the  muscle  fasciculi  are  at 
medium  tension  and  the  skin  is  ordinarily  pliable.     Cold  causes 
contraction  of  these  muscular  bundles  and  they,  embracing  in 
their  action  the  smaller  vessels  of   the  corium,  especially  the 
terminal    capillary   loops    (both   arterial    and    venous)    of   the 
papillae,    produce   blanching   of   the    skin.      Heat   relaxes    the 
muscles;  the  tension  being  relieved,  the  elastic  fibers  return  to 
their  usual  condition  and   the  skin  is   again  soft,   loose,    and 
pliable.     Higher   degrees  cause  increased    relaxation  up  to  a 
certain  point,    where    heightened    tension    is    again    manifest. 
These  facts  explain  the  mechanism  and  the  great  importance  of 
the   contractility   of   the    skin  in  the  propulsive  movement  of 
both  blood  and  lymph.     This  contractility  supplies  the  place  of 
the  muscular  coat  of  the  blood-vessels  which  is  absent  in  this 
situation.     The  elastic  fibers,  forming  as  they  do  a  fine  mem- 
brane around  the  blood-vessels  and  opposing  the  action  of  the 
muscular  fibers,  may  be  supposed  to  support  vasodilatation. 

Baruch— Principles  and  Practice  of  Hydrotherapy,  p.  5. 
3    Hyde  and  Montgomery— Diseases  of  the  Skin,  p.  35. 


PLATE  I.     Diagrammatic  section  of  the  skin. 


THE  BLOOD-VESSELS  41 

The  disappearance  of  elastic  fibers  from  the  skin  in  arterio- 
sclerosis (Meissner)  where  rigidity  and  high  tension  are  essen- 
tial accompaniments,  may  lend  color  to  this  view  and  possibly 
reveal  something:  of  the  pathogenesis  of  high  tension  and  sub- 
sequent vascular  sclerosis. 

THE  BLOOD-VESSELS 

The  blood  vascular  system  of  the  skin  on  the  arterial  side  is 
arranged  in  two  quite  distinct  horizontal  networks — an  upper 
and  a  lower,  besides  being  especially  abundant  about  the  hair 
follicles  and  coil  glands.  The  latter  structures  are  surrounded 
by  a  basket-like  network  of  blood-vessels.  The  lower  or  inferior 
plexus  lies  in  the  deepest  part  of  the  derma.  It  consists  of  com- 
paratively large  vessels.  From  this  plexus,  vessels  extend  more 
or  less  vertically  upward  to  form  the  upper  or  subpapillary 
plexus.  From  this  plexus,  vascular  loops  extend  directly  into 
the  papillae  above.  "In  the  papillary  vascular  system  the 
arteries  are  narrow  and  the  veins  wide." 

Baruch  states  that  the  papillary  loop  may  be  so  filled  with 
blood',  that  it  may  double  and  fold  over  in  spiral  windings  until 
it  occupies  almost  the  entire  space  of  the  papilla.  This  capacity 
for  increasing  or  diminishing  the  size  of  the  papillary  loop 
furnishes  an  important  agency  by  which  hydrotherapy  may  affect 
the  circulation.5 

Both  papillary  veins  and  arteries  consist  of  an  endothelial  tube 
only.  Near  the  middle  of  the  subcutaneous  tissue,  the  media 
and  adventitia  appear.  In  the  veins  the  muscular  coat  is  found 
earlier,  i.  <?.,  in  the  plexus  at  the  base  of  the  derma,  where  they 
also  seem  to  possess  valves.6  In  the  case  of  the  capillary  vessels 
these  coats  are  supplied  by  the  musculo-elastic  tissues  of  the 
skin  itself,  as  mentioned  above.  Vasomotor  nerves  are  twined 
around  these  vessels  in  all  their  ramifications.7 

THE  LYMPHATICS 

The  lymph  vessels  of  the  true  skin  are  also  distributed  in 
two  layers — a  deep  and  wide-meshed  plexus  (collecting  trunks) 

4  Hyde  and  Montgomery — Diseases  of  the  Skin,  p.  29. 

5  Baruch — Principles  and  Practice  of  Hydrotherapy,  p.  6. 

6  Bohm,  Davidoff,  ajid  Huber— Histology,  p.  386. 

7  Hyde  and  Montgomery— Ibid.,  p.  29. 


ANATOMY  AND  PHYSIOLOGY  OF  THE  SKIN 

in  the  subcutis  and  a  superficial  narrow-meshed  plexus  (capil- 
laries) immediately  beneath  the  papillae. "  The  latter  vessels 
(Fig.  5.)  begin  in  the  papillae  as  an  exceedingly  fine  mesh  work 
of  endothelial-lined  and  absolutely  closed  cul-de-sac  spaces  in 
the  connective  tissue.  These  culs-de-sac  divide  and  anasto- 
mose in  a  very  free  manner.  The  capillaries  of  the  subpapil- 
lary  plexus  also  possess  endothelial  walls  of  their  own.  They 
are  devoid  of  valves. 

While  the  lymphatic  capillaries  communicate  neither  with  the 
connective  tissue  spaces  nor  with  the  blood-vessels,  they  are 
nevertheless  in  very  intimate  physiologic  relation  with  both 

these  structures.  Cellular  mi- 
grations and  osmotic  exchanges 
take  place  readily,  so  that  the 
capillaries  fulfill  their  functions 
as  drains,  and  according-  to  Re- 
naut,  selective  drains.9  Accord- 
ing- to  Unna,  the  interspinal 
spaces,  delicate  channeling-s  in 
the  cement  substance  between 
the  epithelial  cells,  are  in  com- 
munication with  the  lymphatic 
spaces  of  the  papillary  region 
of  the  corium.  But,  as  stated 
above,  this  is  not  an  anatomic 
communication,  but  a  physio- 
logical relation  and  is  doubt- 
less the  path  taken  by  sub- 
stances which  are  absorbed  from 

the  skin  surface.  Some  affirm  that  absorption  occurs  partly 
throug-h  the  coil  glands.  The  epithelium  of  excretory  g-lands 
has,  however,  but  slight  absorptive  powers.  At  their  com- 
mencement in  the  capillaries,  the  lymphatics  have  a  capacity 
equal  to  and  greater  than  that  of  the  veins.  This  diminishes, 
the  nearer  we  approach  to  the  thoracic  duct,  the  calibre  of 
which  is  much  smaller  than  that  of  the  vena  cava."' 

Hohm.  Davidoff.  and  Huber— Histology,  p.  387. 
Fourier.  Cuneo.  and  Delamere-The  Lymphatics,  pp.  74  75 
10    I'ouner.  Cuneo.  and  Delamere-lbid.,  p.  62. 


Fix.  5.  Origin  of  lymphatic  vessels 
an  a  papilla  of  the  hand.      (Sappey.) 


THE  LYMPHATICS 


The  deep,  wide-meshed  plexus  located  in  the  subcutis,  forms 
part  of  the  superficial  lymphatics  (collecting-  trunks)  of  gross 
anatomy    (Fig.  6.).      They    are     larger, 
though  very  irregular  and  sacciform  chan- 
nels,   dividing   and    anastomosing-   freely. 
The  wall  consists  of  endothelium,  tog-ether 
with  an  elastic  and  muscular  coat.     They 
-13  are  provided  with  valves  at  variable  dis- 
tances.    From  the  fingers  to  the  axillary 


Fig.  7.    Valves  of  the  mesent'eric  chyliferous  vessels 
of  the  new  born  cat.     (Delamere.) 

g-lands,  Sappey  counted  sixty  to  eighty. 
These  are  crescentic  folds  of  endothelium, 
resembling  the  aortic  semilunar  valves  and 
arranged  in  pairs  (Fig.  7.) .  The  alternate 
constrictions  and  swellings  which  give  the 
lymphatic  vessels  their  beaded  appearance 
are  due  to  these  valves.  According  to 
Delamere,  the  supra  valvular  enlargements 
are  true  contractile  sacs,  similar  to  the 
Fig.  6.  Superficial  iym-  lymphatic  hearts  of  batrachians.  From 

phatics  of  the  arm,  anter- 
ior surface.     Lymphatic  the  standpoint  of  hydro  therapy,   the    fol- 

network    of    fingers   and 

palm,    collecting  trunks  lowing   statement   by    the   same  writer  is 

of  the  arm  and  forearm. 

(Sappey.)  significant.     He  says  that  because  of  the 


44  ANATOMY  AND  PHYSIOLOGY  OF  THE  SKIN 

clastic  fibers,  connective  tissue,  and  muscle,  the  lymphatic 
walls  are,  in  spite  of  their  fineness,  resistant,  extensible,  and 
retractile.  They  withstand,  without  rupture,  the  pressure  of  a 
column  of  mercury  of  from  thirty  to  forty  centimeters." 

We  have  noted  above  the  various  structures  by  which  the 
blood  and  the  lymph  vessels  are  rendered  contractile.  We 
ought  now  to  consider  briefly  the  contractility  of  the  endothe- 
lium.  This  is  of  no  little  importance  in  those  vessels,  the 
blood  and  lymph  capillaries,  which  possess  no  other  coats. 
These  endothelial  cells  contract  and  expand,  causing-  changes 
in  the  calibre  of  the  capillary  channel.  According  to  Foster  1L< 
these  contractions  are  allied  to  the  changes  in  muscle  fibers 
which  constitute  contraction.  Landois  13  states  that  these  motor 
phenomena  are  to  be  observed  especially  after  irritation  in  the 
living  animal.  Schmetkin  found  nerve  fibers  distributed  in  the 
large  blood-vessels,  not  only  in  the  adventitia  and  media,  but 
also  in  the  intima. 14 

It  seems,  then,  a  well  established  fact  that  all  parts  of  the 
vascular  system,  whether  large  or  small,  arterioles,  capillaries 
or  venules,  whether  blood  or  lymph  vessels,  of  whatever  size, 
all  possess  the  power  of  contractility.  Practically  all  the  ves- 
sels of  the  body  are  under  the  control  of  the  nervous  system, 
through  those  filaments  known  as  vasomotor  nerves,  or  are 
played  upon  by  such  contractile  mechanisms  as  the  skin,  which 
is  itself  influenced  by  stimuli  similar  to  those  of  a  vasomotor 
nature.  These  vasomotor  fibers  are  said  to  be  of  two  classes, — 
first,  those  which,  when  stimulated,  produce  vasoconstriction; 
second,  those  that  produce  vasodilatation.  •  The  controversy  as 
to  the  existence  of  the  latter,  or  whether  vasodilatation  is  pro- 
duced by  a  cessation  of  vasoconstrictor  influences,  does  not  con- 
cern us  in  the  practical  application  of  physiologic  measures. 
While  the  vasomotors  originate  in  more  or  less  definite  centers, 
and  seem  to  be  more  abundant  in  certain  localities  and  in  cer- 
tain nerve  trunks,  they  are,  nevertheless,  distributed  with  other 
nerve  fibers,  and  are  found  in  all  parts  of  the  body. 

11  Fourier.  Cuneo,  and  Delamere— The  Lymphatics,  p.  70. 

12  Physiology,  1898.  p.  289. 

13  Human  Physiology.  1905,  p.  132. 

14  Bohm.  Davidoff.  and  Huber— Histology,  p.  223. 


CHAPTER  IV 
THE  PERIPHERAL  HEART 

THAT  the  heart  beat  and  mere  mechanical  elasticity  of  the 
blood-vessels  (like  the  elasticity  of  rubber  tubing)  are  not 
the  only  forces  concerned  in  the  propulsion  of  the  blood  has 
long  been  recognized.  In  a  case  of  hemiplegia,  following  an 
apoplexy,  there  is  a  decided  lowering  of  blood  pressure  on  the 
affected  side  and  a  consequent  stasis,  as  evidenced  by  the 
cyanosis  and  lowered  temperature  on  this  side.  This  can  not, 
of  course,  be  due  to  any  difference  in  the  propulsive  power  of 
the  heart,  since  the  opposite  side  reveals  no  such  marked 
changes  in  its  circulation.  It  can  only  be  due  to  some  disturb- 
ance of  the  vasomotor  mechanism,  resulting  in  changes  in  the 
blood-vessels  themselves,  since  the  causative  lesion  is  confined 
to  the  nervous  system.  The  writer  was  very  forcibly  reminded 
of  this  influence  of  the  blood-vessels  on  blood  pressure  in  a  case 
of  depressed  fracture  of  the  left  cranial  vault,  the  pressure  from 
which  involved  nearly  the  whole  of  the  Rolandic  area  on  this 
side,  including  the  speech  center.  The  radial  pulse  on  the 
right  side  (opposite  the  lesion)  was  scarcely  perceptible,  while 
that  on  the  left  side  was  strong  and  apparently  about  normal. 
Numerous  other  observations  might  be  cited,  showing  the 
effects  of  vasomotor  influences  on  blood  pressure  and  the  circu- 
lation. 

We  may  well  ask,  What  is  the  normal  action  of  the  blood- 
vessels which  plays  such  an  important  part  in  the  propulsion  of 
the  blood  and  the  maintaining  of  blood  pressure  and  which, 
when  interfered  with,  results  in  such  marked  changes.  These 
changes  are,  a  priori,  associated  with  and  dependent  upon  alter- 
ations in  the  calibre  of  the  vessels  themselves.  A  lowering  of 

(45) 


46 

pressure  being  clue  to  a  widening  or  dilatation  of  the  vessels 
and  an  increase  of  pressure  to  the  opposite  condition,  a  narrow- 
ing or  contraction  of  the  vessels.  The  vascular  condition  en- 
tering into  the.  normal  rapidity  of  the  circulation  is  neither  the 
one  nor  the  other  extreme.  A  permanent  widening  of  the 
vessels  leads  to  stasis  of  blood,  while  a  permanent  narrowing 
results  in  heightened  vblood  pressure,  'arteriosclerosis,  and  its 
resultant  chain  of  disasters. 


Figs.  8  and  9.  Blood  pressure  tracings  showing-  Traube-Hering 
curves  taken  from  a  dog.  (Martin.)  The  upper  tracing,  taken 
while  artificial  respiration  was  being  carried  on,  shows  the  three 
curves, — the  pulse  wave,  represented  by  each  double  stroke;  the 
respiratory  wave,  covering  about  five  pulse  waves;  and  the  vaso- 
motor  or  Traube-Hering  wave,  the  slower  undulations  covering 
five  respiratory  waves.  The  lower  tracing,  taken  just  after  the 
cessation  of  artificial  respiration,  shows  only  the  pulse  waves  and 
the  Traube-Hering  waves. 

Traube-Hering  Waves.  In  health  there  are  continuous  and 
more  or  less  rhythmic  alterations  in  the  calibre  of  the  blood- 
vessels. Speaking  along  this  line,  Landois  l  says  the  diameter 
of  the  vessels  "  is  subject  to  periodic  variations,  not  only  in  the 
vessels  provided  with  muscular  tissue,  but  also  in  the  capil- 
laries— in  the  latter,  in  consequence  of  the  spontaneous  con- 
traction of  the  protoplasmic  cells  that  form  their  walls."  More- 

1     Human  Physiology,  1905,  p.  180. 


TRAUBE-HERING  WAVES  It? 

over,  Sir  Michael  Foster  states  that  these  changes  which  vary 
considerably,  both  in  their  rhythm  and  extent,  occur  without 
any  obvious  changes  in  either  the  heart  beat  or  the  general  cir- 
culation, and  when  the  animal  (under  observation)  is  appar- 
ently subjected  to  no  disturbing  causes.  He  regards  them  as 
spontaneous,  although  subject  to  vasomotor  control. 

In  determining  changes  in  the  amount  of  blood  in  the  arm  by 
the  plethysmograph ,  the  fluctuations  in  volume,  as  registered 
by  the  kymograph,  permit  recognition  of  the  following  phe- 
nomena.2 {Figs.  8  and  9.)  1.  Pulsatory  fluctuations  due  to 
each  individual  heart  beat.  2.  Respiratory  fluctuations.  3.  Cer- 
tain periodic  fluctuations  dependent  upon  periodic -regulatory 
movements  of  the  blood-vessels,  particularly  the  smaller  vessels. 


Fig.  10.  Rhythmical  vasomotor  waves  of  blood  pressure  in  a  dog 
(Traube-Hering  waves) .  The  upper  tracing  (1)  is  the  blood  pressure 
record  as  taken  with  the  mercury  manometer;  the  lower  tracing  (2) 
is  taken  with  a  Hurthle  manometer. 

"Waves  are  often  observed  on  the  blood  pressure  curve, 
which  must  arise  in  a  slow  rhythmic  variation  of  the  constrictor 
impulses  sent  out  from  the  vasomotor  center.  These  waves  are 
known  as  the  Traube-Hering  curves."  Relative  to  the  blood 
pressure  tracing  as  taken  with  a  mercury  manometer  (Fig.  10) 
Howell 4  says,  "The  latter  waves  (Traube-Hering)  are  .  .  . 
due  to  a  rhythmic  action  of  the  vasomotor  center.  During 
sleep,  certain  much  longer,  wave-like  variations  in  the  blood 
pressure  also  occur  that  are  again  due,  doubtless,  to  a  rhythmic 

2  Landois — Human  Physiology,  p.  190. 

3  Starling — Elements  of  Human  Physiology,  p.  276. 

4  Physiology,  1908,  pp.  564,  565. 


48  THE  PERIPHERAL  HEART 

change  of  tone  in  the  vasoconstrictor  center."  Changes  similar 
to  those  producing  the  Traube-Hering  wave  may  also  be 
observed  in  the  spleen  (See  Chapter  X.}  and  in  heart  muscle 
(Fig.  7/J.  The  manifestation  of  periodic  variations  in  tone 
is,  therefore,  common  to  the  involuntary  muscle  of  several 
different  organs  and  structures.  Some  observers  regard  these 
tone  waves  as  spontaneous,  though  subject  to  nerve  control. 

In  discussing  periodic  variations  in  blood  pressure  Janeway  ' 
gives  the  following:  "These  are  evident  in  the  human  being  as 
in  the  animal.  The  respiratory  and  the  Traube-Hering  waves, 


Fig.  11.  Tone  waves  in  heart  muscle.  The  record  shows  contrac- 
tions of  a  strip  of  the  sinus  venosus  (terrapin's  heart)  suspended  in 
a  bath  of  blood-serum.  In  addition  to  the  sharp  contractions 
marked  by  the  lines  there  are  longer,  wave-like  shortenings  and 
relaxations,  irregular  in  character,  which  are  due  to  variations  in 
tone.  (Howell.) 

and  the  other  less  rhythmical  but  apparently  spontaneous  fluc- 
tuations in  mean  blood  pressure,  must  be  in  mind  during  every 
clinical  experiment.  .  .  .  Exact  figures  for  the  possible  press- 
ure variations  due  to  these  causes  are  hard  to  give,  but  their 
extent  in  animals,  combined  with  my  observations  on  the 
changes  noted  in  patients  from  moment  to  moment,  lead  me  to 
place  30  mm.  Kg.  as  the  probable  maximum  rise  which  may  be 
attributed  to  them.  One  sees  these  larger  fluctuations  mainly 
in  patients  with  hypertension.  Ordinarily,  5 — 10  mm.  would  be 
a  liberal  estimate."  In  this  connection  Janeway  gives  a  trac- 
ing (/•/>.  /2.)  by  Mosso,  taken  from  a  man  at  rest,  in  which  the 
Traube-Hering  wave  covers  on  an  average  of  fifteen  pulse 

5    Clinical  Study  of  Blood  Pressure,  pp.  112,  113;  s?e  also  pp.  16—21. 


VASCULAR  EFFECTS 


49 


waves,  thus  showing-  a  fluctuation  recurring  about  four  or  five 
times  a  minute. 

Events  occurring  in  other  parts  of  the  body  may  give  rise  to 
large  changes,  so  that  the  arterioles  may  become  constricted 
almost  to  obliteration,  or  dilated  to  more  than  double  their 
usual  diameter.  These  observations  apply  to  arteries,  capil- 
laries, and  veins.  In  the  vessels  of  the  web  of  a  frog's  foot, 
direct  treatment  of  the  web  may  bring  about  the  same  changes. 

Since  these  rhythmic  vascular  changes  normally  occur  quite 
independently  of  the  heart  beat,  we  have  here  a  factor  in  the 
circulation  which,  under  proper  physiologic  stimulation,  may 
be  utilized  to  relieve  that  organ  of  much  of  its  work,  so  that 


Pig.  12.    Periodic  fluctuations  in  the  tracing  of  blood  pressure 
taken  from  Doctor  Colombo  (at  rest).      (Mosso  s  sphygmograph.) 

when  overburdened,  it  may  obtain  needed  rest  through  the 
slowing  of  the  rate  and  the  increasing  of  the  force  consequent 
upon  this  help.  Landois,6  in  discussing  blood  pressure  as 
altered  by  changes  in  the  size  of  the  vessels,  mentions  the 
application  of  heat  and  cold  to  circumscribed  areas  as  influenc- 
ing blood  pressure  through  the  vasomotor  nerves.  It  is  to  the 
applications  which  bring  about  such  changes  as  these  that  we 
now  turn  our  attention. 

THE  PRINCIPLES  OF  VASCULAR  EFFECTS 

The  underlying  principle  of  applications  calculated  to  awaken 
an  activity  of  the  circulation  is  found  in  the  old  dictum,  ubi  ir- 
ritatio,  ibi  affuxus.  Where  there  is  an  irritation,  there  is  an 


6    Human  Physiology,  p.  166. 


50  THE  PERIPHERAL  HEART 

afflux  of  blood.  Rub  vigorously  the  back  of  the  hand  and  the 
skin  becomes  reddened  with  an  increase  of  blood.  Percussion 
or  a  dash  of  cold  water  produce  the  same  results.  These  are 
examples  of  what  we  may  term  physiologic  irritation.  All  forms 
of  irritation  produce  an  initial  contraction  of  the  blood-vessels, 
; .  e. ,  the  primary  effect  of  an  irritation  from  any  source  is  con- 
traction. The  oscillatory  changes  which  soon  result  (reaction) 
are  different  with  the  different  kinds  of  irritation.  In  fact,  it  is 
this  reaction  with  which  we  are  principally  concerned.  In  some 
cases  the  first  effect  is  of  no  practical  importance,  while  in 
others,  it  is  utilized.  Heat,  for  example,  causes  an  initial  vaso- 
constriction.  The  secondary  vascular  contractions  are  slight 
and.  become  less  and  less  the  greater  the  duration  of  the  appli- 
cation, so  that  a  prolonged  application  of  heat  results  in  a  maxi- 
mum dilatation.  The  remote  effect  is  not  a  reddening  of  the 
skin  from  quickened  circulation,  but  a  slight  duskiness  from 
stasis  of  blood  (passive  hyperemia).  These  are  the  effects  of  a 
fomentation,  heating  compress,  radiant  heat,  etc.  The  reaction 
to  heat  is,  therefore,  of  an  atonic  and  depressing  nature. 

With  a  cold  application  to  the  skin,  the  first  effect  is  a  blanch- 
ing (vasoconstriction),  but  this  is  soon  followed  by  a  reddening 
(active  hyperemia)  which,  as  we  know,  is  maintained  for  a  con- 
siderable length  of  time  and  does  not  result  in  a  dusky  color. 
Here,  the  oscillations  in  vascular  calibre  are  stimulated  in  such 
a  way  that  they  are  greater,  more  forcible  and  do  not  tend  to 
passive  dilatation.  This  is  the  reactionary  effect  of  cold.  Me- 
chanical irritation,  such  as  friction  and  percussion,  give  similar 
results.  However,  the  two  combined,  as  in  the  cold  mitten  fric- 
tion, cold  percussion  douche,  etc. ,  give  quicker,  better,  and  more 
lasting  effects. 

Kellogg 7  records  the  following  experiment  as  showing  the  ad- 
vantage of  mechanical  irritation  combined  with  cold.  A  cold 
compress  and  a  percussion  douche,  both  at  65°  F.,  were  simul- 
taneously administered  to  opposite  and  corresponding  parts  for 
five  seconds.  After  the  cold  compress  the  reaction  appeared  in 
forty  seconds,  whereas,  after  the  cold  percussion  douche,  the 
circulatory  reaction  appears  in  five  seconds. 

7    Rational  Hydrotherapy.  1901.  p.  1126. 


VASCULAR  EFFECTS  51 

As  the  cold  application  is  prolonged,  the  amplitude  of  the  vas- 
cular oscillations  becomes  less  and  less  until  the  condition  is 
more  nearly  that  of  a  constant  vasoconstriction.  "Following 
the  process  to  an  extreme  point,  we  find  that,  by  intensely  low 
temperatures,  the  circulation  in  the  capillaries  is  at  first  accel- 
erated and  the  number  of  blood  corpuscles  diminished,  when 
the  part  becomes  pale.  Quickly  following  this  acceleration 
there  is  a  stasis  in  the  capillaries,  while  in  the  smaller  veins  and 
arteries,  the  slowing  of  the  circulation  is  followed  by  brief  and 
rapid  oscillations,  which  become  slower  and  more  infrequent. 
Slowly  the  vessels  become  more  pale,  less  transparent,  and 
finally  the  movements  cease."  This  is,  of  course,  providing 
reaction  occurs  at  all,  as  it  usually  does  if  the  cold  is  applied  to 
a  limited  area.  If  the  reaction  does  not  occur,  as  where  there 
is  a  general  application  of  cold  without  friction,  the  skin  be- 
comes blanched  and  goose  flesh  appears,  due  to  the  contraction 
of  the  erectores  pilorum.  In  case  an  ice-cold  application  re- 
mains long  enough  on  one  part,  paralysis  of  the  vessels  results 
and  a  consequent  dilatation. 

Saline  substances  and  certain  gaseous  irritants,  chief  among 
which  is  COa,  when  applied  to  the  skin,  also  produce  an  active 
dilatation  and  contraction  of  the  blood-vessels  which  results  in 
quickened  circulation  and  increase  of  blood  in  the  skin.  Saline 
baths  are  often  more  effective  than  plain  water.  Carbon  dioxide 
and  salines  are  most  effectively  used  in  the  combination  consti- 
tuting the  Nauheim  or  effervescent  bath.  Here  the  cool  water 
itself  plays  some  part,  since  temperatures  somewhat  below  neu- 
tral are  used.  "  So  marked  is  the  effect  of  this  skin  tonic  that 
in  severe  cases  of  dilatation  (of  the  heart)  the  almost  incredible 
result  is  attained,  of  causing  the  apex  actually  to  retract  three 
quarters  of  an  inch  toward  its  normal  position  in  a  single  treat- 
ment." The  heart  beat  is  decreased  in  frequency  and  in- 
creased in  force;  its  previously  labored  beat  gives  way  to  a 
steady,  easy  movement  and,  in  some  cases,  we  have  actually 
been  unable  to  detect  murmurs  which  were  previously  distinctly 
heard.  These  results  are  by  all  conceded  to  be  due  chiefly,  if 


8  Baruch— Principles  and  Practice  of  Hydrotherapy,  p.  39. 

9  Baruch— Ibid.,  p.  10. 


5g  THE  PERIPHERAL  HEART 

not  almost  wholly,  to  the  stimulation  of  the  great  vascular  area 
of  the  skin,  the  so-called  "  peripheral  heart  "  or  "  skin  heart." 
When  we  consider  the  magnitude  of  this  peripheral  heart,  it  no 
longer  becomes  a  wonder  that  its  influence  is  so  powerful. 
Yierordt  estimates  the  combined  calibres  of  the  capillaries  of  the 
systemic  circulation  at  800  times  that  of  the  aorta  in  cross  sec- 
tion. With  this  fact  in  mind,  we  may  gather  some  idea  of  the 
magnitude  of  the  effect  produced  by  saline  and  gaseous  irritants 
acting  simultaneously  upon  such  a  great  system  of  contractile 
tubes.  Such  results  can  not  be  obtained  by  digitalis  or  strych- 
nine. That  these  results  are  not  due  to  simple  atonic  vasodila- 
tation  is  shown  by  the  fact  that  these  patients  are  frequently 
cyanotic,  an  evidence  of  already  existing  venous  stasis  and  vaso- 
dilatation,  while  on  emerging  from  the  bath,  the  skin  is  of  a 
brighter  and  more  normal  color.  Neither  vasodilatation  nor 
vasoconstriction  are  conducive  to  a  slower,  easier  heart  beat. 
The  result  is,  therefore,  not  a  passive  change,  but  an  active  one. 
Electric  currents  applied  to  the  skin  also  stimulate  the  vaso- 
motors.  Near  the  positive  pole  vasoconstriction  is  manifest, 
while  in  the  region  of  the  cathode  vasodilatation  occurs.  With 
alternating  or  interrupted  currents  the  vasomotors  are  much 
more  powerfully  stimulated.  This  stimulation  is  greatest  with 
the  sinusoidal  current,  the  use  of  which  in  the  obtaining  of  vas- 
cular effects  will  be  mentioned  more  in  detail  in  the  part  on 
therapeutics. 

THE  QUANTITY  OF  CIRCULATING  FLUIDS 

When  we  consider  the  total  quantity  of  blood  and  lymph  in  the 
body,  and  the  fact  that  the  skin  and  adjacent  tissues  may  con- 
tain a  large  share  of  this,  or  influence  its  distribution  elsewhere, 
we  see  how  powerful  an  agent  the  skin  is  in  controlling  the  cir- 
culation of  these  fluids  in  the  various  organs. 

About  one-thirteenth  of  the  body  weight  is  blood.  Of  this, 
nearly  30  per  cent  may  be  contained  in  the  skin  under  the 
influence  of  certain  conditions  and  applications.  Ordinarily, 
there  is  one-fourth  of  the  blood  in  the  heart,  lungs,  and  great 
blood-vessels;  one-fourth  in  the  liver;  one-fourth  in  the  skeletal 
muscles;  and  one-fourth  in  other  organs.  The  circulation  of  the 


CIRCULATING  FLUIDS  53 

skeletal  muscles  is  influenced  with  that  of  the  skin,  and  usually 
the  same  changes  occur  simultaneously  in  both. 

The  amount  of  lymph  in  the  body  is  variously  estimated  from 
one-fourth  or  one-fifth  to  one-third  of  the  entire  body  weight.10 
This  enormous  quantity  of  fluid  is  affected  in  the  same  way 
by  physiologic  applications  as  the  blood. 

Kowalski,11  in  1901,  reported  a  series  of  experiments  under- 
taken to  determine  the  effects  of  thermic  irritants  upon  the 
movement  of  lymph  and  upon  the  vasomotor  nerves  of  the 
lymph  vessels.  Briefly  stated,  his  conclusions  are  as  follows: — 

Thermic  irritants  control  the  flow  of  lymph,  not  only  indi- 
rectly, but  also  by  altering  the  calibre  of  the  lymph  vessels. 
These  changes  are  the  same  as  those  in  the  blood-vessels,  i.  e., 
low  temperatures  contract  them,  while  high  temperatures  dilate 
them.  These  effects  are  produced  through  the  nervous  system 
by  way  of  the  vasomotor  nerves.  The  vasomotor  nerves  of  the 
lymphatic  vessels  act  independently  of  those  controlling  the 
blood-vessels  and  general  circulation.  It  will  be  seen  from  this 
that  the  use  of  the  alternate  hot  and  cold  leg  bath  for  oedema  is 
based  upon  demonstrated  physiologic  facts,  the  lymphatics  as 
well  as  the  blood-vessels  taking  part  in  the  absorption  of  tissue 
fluids. 

Experiments  on  the  production  of  lymph  in  the  limbs  have 
also  brought  out  in  a  very  striking  manner  the  rationale  of 
massage  in  dropsy.  In  the  resting  limb  there  is  no  flow  at  all 
from  the  tissue  spaces.  Berlin  blue  injected  under  the  skin 
finds  its  way  into  the  lymphatics  with  extreme  slowness,  unless 
absorption  is  facilitated  by  kneading  the  limb  or  by  carrying 
out  passive  movements.  "  Ludwig  has  shown  that  the  lym- 
phatics of  the  aponeuroses.  are  so  arranged  that  every  move- 
ment, active  or  passive,  tends  to  pump  fluid  from  the  tissue 
spaces  into  the  lymphatics,  and  from  the  smaller  into  the  larger 
lymph  trunks.  Experiments  on  the  production  of  lymph  in  the 
limbs  have,  therefore,  always  to  be  associated  with  kneading  or 
passive  movements  in  order  to  get  any  lymph  flow  at  all." 

10  Fourier,  Cuneo,  and  Delamere — The  Lymphatics,  p.  7. 

11  Blatter  fur  klinische  Hydrotherapie,  January  and  February.  1901. 

12  Starling— Fluids  of  the  Body,  p.  72. 


CHAPTER   V 
ANATOMY  AND  PHYSIOLOGY  OF  THE  SKIN 

(Continued) 

THE  SUDORIPAROUS  OR  COIL  GLANDS 

THE  sweat  glands  are  distributed  throughout  the  entire  skin. 
They  are  most  numerous  in  the  axilla,  palms,  and  soles, 
where  they  are  also  of  unusual  size.  And,  according  to  Krause, 
there  are  between  2000  and  3000  per  square  inch.  The  total 
number  in  the  body  is  estimated  at  from  2,000,000  to  3,000,000, 
and  their  aggregate  length  uncoiled  and  placed  end  to  end,  as 
about  eight  miles;  while  the  total  surface  of  the  ducts  is  estim- 
ated at  11,000  square  feet.  These  figures  serve  to  show  the 
great  importance  of  hygiene  directed  toward  the  maintaining  of 
their  normal  functions  and  the  tremendous  effect  of  bad  hygiene 
in  causing  disease. 

The  sweat  gland  consists  of  a  long  tubule,  coiled  at  the 
deeper  end.  The  globular  coil  (glomerulus)  lies  in  the  sub- 
cutaneous fat,  or  in  the  fat  columns  of  the  deeper  part  of  the 
corium.  Next  to  the  epithelium  in  the  coiled  part  of  the  tubule, 
are  found  smooth  muscle  fibers,  disposed  longitudinally,  or 
spirally.  These  muscle  fibers  are  doubtless  concerned,  along 
with  the  erectores  pilorum,  in  the  checking  of  perspiration 
which  results  from  cold  applications.  Each  tube  is  about  four 
or  five  millimeters  long.  Three-fourths  of  this  makes  up  the 
coil.1  The  sweat  pore — that  part  of  the  duct  lying  in  the  epi- 
dermis— is  a  wall-less  channel,  spiral  or  straight  in  course. 
The  outer  end  is  funnel-shaped.  The  pore  is  in  free  communi- 
cation with  the  juice  spaces  of  the  epithelium,  as  was  mentioned 
in  considering  the  lymphatics  of  the  skin.  It  will  be  seen  from 

1     Bohm.  Davidoff,  and  Huber— Histology    p  397 
(54) 


THE  COIL  GLANDS 


55 


this  fact  that  the  drying  of  the  skin  is  not  alone  a  drying  of  the 
surface,  but  also  a  drying  of  the  fluid  found  between  the  deeper 
cells  of  the  epidermis.  A  capillary  network  of  blood-vessels 
surrounds  the  coiled  part  of  the  gland.  Nerves  from  the  sym- 
pathetic neurons  end  in  the  secreting  cells. 


Figs.  13  and  14.  Diagrams  showing  similarity  in  structure  of  the 
tubules  and  glomeruli  of  the  kidney  to  the  coil  glands  of  the  skin 
and  their  vascular  network.  As  the  uriniferous  tubules  are  many 
times  the  length  of  the  coil  glands,  no  comparison  of  the  size  is  in- 
dicated by  the  drawings.  Fig.  13.  U.  T. — uriniferous  tubule,  C.  B. 
— capsule  of  Bowman,  G. — glomerulus.  Fig.  14.  Sudoriparous 
gland:  E.-j«pithelium  of  skin,  P.  D.—  perspiratory  duct,  C.  G. — 
coiled  portion  of  gland,  V.  N. — vascular  network. 

The  secretion  of  the  sweat  glands  varies  with  the  character 
and  amount  of  food  and  drink,  the  state  of  health,  temperature 
and  humidity  of  the  air,  etc.  About  98  per  cent  is  water,2  the 
remainder  being  chiefly  salines,  pigment,  and  a  small  amount 
of  fat.  In  twenty -four  hours,  one  and  one-half  or  two  pints  of 
water  are  excreted.  This  is  approximately  double  the  amount 


2     Hyde  and  Montgomery — Diseases  of  the  Skin,  p.  46. 


56  ANATOMY  AND  PHYSIOLOGY  OF  THE  SKIN 

exhaled  by  the  lungs.  Contrary  to  the  general  notion,  the  skin 
does  not  excrete  large  quantities  of  deleterious  substances.  In 
health  the  poisons  excreted  by  the  skin  are  very  small  in  amount. 

Vicarious  Functions  of  the  Skin.  There  is  a  great  similarity 
in  the  structure  of  the  tubules  and  glomeruli  of  the  kidney  to 
the  coil  glands  of  the  skin  and  their  vascular  tufts  (Figs.  13  and 
14.).  This  very  similarity  in  structure  suggests  a  similarity  in 
function.  The  perspiration  and  urine  are  both  excretions  and, 
to  a  great  extent,  may  replace  each  other.  In  disease  this  fact 
becomes  very  evident.  When  the  kidneys  become  incompetent 
to  excrete  certain  wastes,  these  are  often  found  in  the  sweat 
and,  vice  versa,  when  perspiration  is  interfered  with,  more 
work  is  thrown  on  the  kidneys.  In  warm  weather  excessive 
perspiration  occurs,  while  the  urine  is  scanty.  In  cold  weather 
the  perspiration  decreases  and  the  urine  increases  in  amount. 

Urea,  normal  in  the  urine  to  the  extent,  of  about  2  per  cent, 
is  found  in  normal  perspiration  to  the  extent  of  0.1  to  0.2  per 
cent.  Schottein,  in  certain  cases  of  the  uremia  of  cholera,  saw 
the  whole  body  covered  with  a  thin  white  crystalline  layer  of 
urea.3  In  cases  of  pyemia,  where  the  staphylococcus  albus  was 
present  in  the  blood,  the  sweat  induced  by  packs  has  shown 
abundance  of  the  staphylococcus.  The  same  is  true  of  many 
other  diseases  in  which  there  are  germs  in  the  blood  (bacteri- 
emia),  the  kidneys  also  excreting  the  germs.  Bouchard4  has 
called  particular  attention  to  the  cutaneous  eruptions  which 
accompany  auto-intoxication,  especially  with  a  dilated  stomach, 
or  after  eating  mussels,  shell-fish,  etc.,  as  being  due  to  pto- 
maines eliminated  through  the  skin.  In  some  forms  of  auto- 
intoxication various  poisons  excreted  by  the  skin  may  be  appre- 
ciated by  their  odors.  The  peculiar  odors  about  prisons  and 
asylums  are  doubtless  more  or  less  due  to  the  volatile  poisons 
of  faulty  nutrition  which  the  skin  exhales.  In  cases  of  jaundice 
bile  pigments  are  found  in  the  sweat  so  that  sheets  and  bedding 
are  stained  by  it.  Sugar  may  be  found  in  the  sweat  of  dia- 
betics and  in  the  sweat  of  cases  of  forced  glycosuria. 

Dr.   Herbert  U.   Williams  of   Buffalo   has    shown5   that    in 

3  Baruch— Principles  and  Practice  of  Hydrotherapy,  p.  26. 

4  Auto-Intoxication  in  Disease,  pp.  20,  162. 

5  Journal  of  American  Medical  Association,  April  17,  1909,  p.  1276. 


PERSPIRATORY  INFUENCES  57 

chronic  nephritis  the  sweat  glands  are  extensively  altered  in 
structure.  He  examined  skin  from  various  parts  in  seventy 
cases  of  chronic  nephritis  and  found  a  variety  of  conditions 
including  desquamation  of  the  epithelium,  cystic  dilatation  of 
the  tubules,  atrophy  of  the  tubules,  and  cast-like  material  in 
the  tubules.  In  fourteen  cases  arteriosclerosis  of  the  arteries 
of  the  skin  was  present.  In  some  cases  hypertrophy  of  the 
epithelium  was  observed,  even  to  the  formation  of  two  or  three 
layers  of  cells.  Dr.  Williams  states  that  these  studies  were 
undertaken  because,  from  the  earliest  ages,  faith  has  been 
placed  in  the  efficacy  of  active  skin  excretion  in  cases  of 
nephritis. 

SUMMARY  OF  PERSPIRATORY  INFUENCES 

Factors  which  govern  perspiration: — 

1.  Degree  of  internal  or  external  heat. 

2.  Amount  of  water  in  the  body. 

3.  Amount  of  blood  in  the  skin. 

4.  Specific   stimulation  of  secretory    (sweat)   nerves,    as  by 
electricity,  shock  (as  cold  sweat  of  fright,  etc.),  and  drugs. 
Conditions  that  give  rise  to  increase  of  perspiration: — 

1.  Applications  of  heat,  as  hot  air,  hot  water,  steam,  light. 

2.  Water  drinking,  especially  of  hot  water. 

3.  Exercise. 

4.  Mechanical  irritation,  as  friction  or  percussion. 

5.  Diaphoretic  drugs. 
Conditions  that  decrease  perspiration: — 

1.  Chilling  or  cold  applications. 

2.  Excretion  of  large  amounts  of  water  by  the  kidneys  or 
bowels. 

3.  Certain  drugs,  as  atropine. 

4.  Local  applications  of  astringents,  or  cooling  preparations, 
as  alcohol,  vinegar,  talcum  powder,  etc. 

The  facts  listed  in  the  above  outline  are  perhaps  too  evident 
as  matters  of  every-day  experience  to  need  comment.  In  prac- 
tice we  usually  combine  two  or  more  of  these  measures  in  order 
to  secure  quicker  and  better  results.  For  example,  the  drink- 
ing of  cold  water  before  and  during  the  electric  light  bath 


58  ANATOMY  AND  PHYSIOLOGY  OF  THE  SKIN 

greatly  enhances  its  results.  The  drinking-  of  hot  lemonade  in 
conjunction  with  hot  packs,  vapor  or  Russian  baths,  likewise 
gives  quicker  results.  Heat  applied  to  the  skin,  not  only  in- 
creases the  blood  about  the  coil  glands,  but  also  stimulates, 
directly,  the  secreting-  cells.  Cold,  applied  to  the  skin,  causes 
a  decrease  in  the  amount  of  the  blood  in  the  skin  and  so  lessens 
the  available  fluid  which  the  sweat  glands  utilize  for  secretion. 
It  has  been  shown  that  drugs  having  a  specific  action  upon 
the  sweat  glands,  cause  alterations  in  the  structure  of  the  secret- 
ing cells,  thus  proving  detrimental  to  their  healthy  activity. 

THE  SEBACEOUS  GLANDS 

The  sebaceous  glands  are  sacciform  in  shape,  found  in  con- 
nection with  the  hairs  of  the  skin  and  pouring  their  secretion 
into  the  follicles  of  the  hair  and  lanugo.  The  oil  or  sebum  is 
produced  by  fatty  degeneration  of  the  gland  cells  themselves; 
more  cells  being  produced  next  the  basement  membrane  to  take 
their  place.  It  is  designed  to  oil  the  hair  and  skin.  The  glands 
are  situated  next  the  hair  follicle,  between  it  and  the  piliary 
muscle.  Heat  softens  the  oil  in  the  glands,  and  thereby  brings 
about  its  extrusion.  Oil  is  a  non-conductor  of  heat.  Covering 
the  skin  with  oil  hinders  both  the  elimination  of  heat  where  the 
surrounding  atmosphere  is  cold,  and  the  absorption  of  heat 
where  the  atmosphere  is  heated. 

ABSORPTION  BY  THE  SKIN 

We  are  not  greatly  concerned  in  hydrotherapy  with  the  ab- 
sorptive powers  of  the  skin.  Oily  substances  are  most  readily 
absorbed,  watery  solutions  not  at  all.  Absorption  of  oily  sub- 
stances, alcoholic  or  ethereal  solutions  is  greater  after  a  warm 
bath  and  cleansing  of  the  skin,  since  the  sweat  pores  are  then 
open  and  the  increased  circulation  favors  absorption. 

Guy  Hinsdale 6  gives  an  excellent  summary  of  the  subject  of 
cutaneous  absorption  from  which  we  quote  the  following: — 

"James  Currie,  who  wrote  one  of  the  first  and  best  books  on 
hydrotherapy,  states  that  there  is  no  increase  of  weight  in  the 
bath,  and  while  the  skin  remains  sound  and  entire  no  absorp- 
tion of  solid,  liquid,  or  aeriform  elastic  fluid  takes  place  on  the 

6    Hydrotherapy.  p.  21. 


CUTANEOUS  RESPIRATION  59 

surface.  In  the  instances  that  are  supposed  to  favor  the  con- 
trary opinion,  it  will  be  found  that  the  article  is  forced  through 
the  epidermis  by  mechanical  pressure,  or  that  the  epidermis  has 
been  previously  destroyed  by  injury  or  disease." 

Rohrig  in  experimenting-  with  a  bath  to  which  potassium 
iodide  had  been  added,  found  that  full  immersion  in  this  for 
three-quarters  of  an  hour  gave  rise  to  no  iodine  in  the  urine. 
Negative  results  have  also  been  obtained  by  a  number  of  other 
observers  using  various  soluble  substances.  Substances  caus- 
ing injury  to  the  skin  may  be  absorbed,  also  ethereal  solutions 
of  certain  alkaloids,  but  R.  Winternitz  found  no  evidence  of  the 
entrance  of  these  substances  from  watery  solutions. 

One  must,  therefore,  conclude  that  the  mineral  constituents 
of  water — other  than  strong  salines  and  gaseous  constituents — 
have  no  effect  whatever  upon  the  human  system  when  applied 
to  the  unbroken  skin.  Hinsdale  makes  a  very  apt  statement  of 
the  case,  "We  are  thus  forced  to  the  conclusion  previously 
enunciated, — that  the  mineral  waters,  the  analysis  of  which  are 
quoted  with  such  particular  exactitude  unto  the  third  or  fourth 
decimal  place  of  grains  per  gallon,  are  neither  more  or  less  effi- 
cacious on  that  account." 

CUTANEOUS  RESPIRATION 

To  a  limited  extent,  the  skin  acts  as  a  respiratory  organ  when 
the  temperature  is  above  85°  F.  About  0.5  per  cent  of  the  total 
gaseous  exchange  of  the  body  occurs  in  this  manner.  The 
amount  of  CO2  exhaled  at  91.4°  F.  may  be  doubled  at  93°  F., 
increasing  in  about  the  same  ratio  as  the  watery  excretion. 
Hot  moist  applications  to  the  skin  increase  the  elimination  of 
COz,  since  diffusion  of  gases  is  hastened  by  the  moistening  of 
the  surface  and  the  larger  amount  of  blood  brought  to  the  skin. 
It  is  said  that,  in  diseases  of  the  heart  and  lungs,  where  there 
is  diminished  excretion  of  COz  in  the  expired  air,  cutaneous  ex- 
halation is  increased.  In  asthmatic  dyspnoea  when  the  skin 
becomes  flushed  and  perspiration  free,  the  dyspnoea  is  somewhat 
relieved.  General  perspiration  produced  by  hot  applications 
also  relieves  dyspnoea.  In  either  case,  however,  the  result  is 
probably  due  more  to  the  increased  rate  of  the  circulation  of 


60  ANATOMY  AND  PHYSIOLOGY  OF  THE  SKIN 

blood  through  the  lung's  reflexly  produced  by  the  application, 
thus  increasing-  the  amount  of  oxygen  there  absorbed,  than  to 
increase  of  cutaneous  respiration. 

THE  SKIN  A  HEAT  REGULATOR 

This  will  be  considered  again  under  the  subject  of  heat  regu- 
lation. The  skin  itself  takes  part  in  heat  loss  only,  although 
through  nerve  connection,  it  is  one  of  the  most  important  means 
in  controlling  heat  production.  '  The  loss  of  heat  by  the  skin 
amounts  to  about  77  per  cent  of  the  total  heat  loss. ' ' 7  It  is,  there- 
fore, the  most  important  factor  in  the  elimination  of  heat.  The 
regulation  of  heat  loss  by  the  skin  is  accomplished  by  variations 
in  the  amount  of  heat  radiation  and  evaporation  of  sweat. 

It  will  be  seen  that  heat  applied  to  the  skin  increases  heat 
loss  in  two  ways:  first,  by  dilating  the  surface  vessels  and  quick- 
ening cutaneous  circulation,  thus  increasing  heat  radiation  and 
convection;  second,  by  inducing  free  perspiration  and  the  con- 
sequent loss  of  heat  by  evaporation.  Conversely,  cold  applied 
to  the  skin  decreases  heat  loss  by  driving  the  blood  inward  and 
checking  perspiration. 

It  is  chiefly  through  the  temperature  nerves  of  the  skin  that 
this  organ  influences  heat  production.  So  profound  is  this 
influence  that  extensive  burns,  covering  more  than  two-thirds 
of  the  body,  are  fatal  through  destruction  of  the  sensory  nerve 
terminals.  Not  only  is  heat  elimination  interfered  with,  but 
metabolism  becomes  excessive  and  heat  production  is  immensely 
increased.  Internal  congestion  and  inflammations  result,  with 
a  fatal  termination. 

After  a  drunken  debauch  the  unfortunate  victim  is  in  great 
danger  from  exposure  to  cold,  because  the  sensibility  of  the 
nerves  is  temporarily  destroyed,  so  that  the  heat-regulating 
centers  are  not  apprised  of  the  danger.  The  boy  who  died  from 
gilding  of  the  skin  to  represent  an  angel  is  an  example  of  the 
disturbance  of  the  heat  mechanism  due  to  interference  with  the 
regulatory  functions  of  the  skin.  After  varnishing  of  the  skin 
the  temperature  at  first  rises  and  then  falls  accompanied  by 
symptoms  of  poisoning  due  to  defective  oxidation. 

7    Starling— Human  Physiology,  p.  505. 


CUTANEOUS  NERVES  61 

NERVES  OF  THE  SKIN 

We  have  already  considered  the  secretory  and  vasomotor 
nerves  of  the  skin.  The  third  set  of  cutaneous  nerves  of  impor- 
tance in  hydrotherapy  are  those  already  mentioned  as  forming 
the  connection  by  which  the  skin  regulates  heat  production  and 
loss,  viz.,  temperature  nerves.  These  nerves  are  not  uniformly 
distributed  in  the  skin.  They  are  more  numerous  in  certain 
localities  than  in  others,  and  where  more  numerous,  the  tem- 
perature sense  is  more  acute,  such  as  the  tips  of  the  fingers, 
the  cheeks,  and  backs  of  the  hands.  These  are  the  parts  we 
instinctively  use  to  test  the  safety  of  hot-water  bottles  and  other 
hot  applications. 

The  recognition  of  heat  is  confined  to  the  ' '  hot  spots  ' '  and 
that  of  cold  to  the  "  cold  spots,"  as  can  readily  be  proven  by 
experiment.  Lightly  resting  the  point  of  the  pencil  on  the  skin 
will  produce  a  sensation  of  heat  or  cold  according  as  it  rests  on 
a  hot  or  cold  spot.  The  two  sensations  are  appreciated  by  dif- 
ferent end  organs  and  travel  by  different  fibers. 

Applications  to .  certain  localities  produce  more  intense  tem- 
perature sensations  than  to  others.  Applications  to  a  large  area 
produce  a  greater  intensity  of  sensation  than  applications  to  a 
smaller  area.  These  facts  are  utilized  in  controlling  the  circu- 
lation reflexly  and  mechanically  (q.  v.) .  The  temperature  sense 
is  more  acute  when  the  skin  is  warm  or  after  warm  applica- 
tions. This  fact  is  utilized  to  prepare  the  body  for  cold  appli- 
cations, so  that  the  reaction  will  be  greater  and  appear  more 
promptly.  As  has  been  mentioned,  the  temperature  of  the  skin 
is  the  zero  of  the  temperature  sense. 

The  skin  contains  also  the  end  organs  of  tactile  sensation. 
They  are  more  numerous  in  certain  localities  than  in  others,  as 
are  the  temperature  nerves,  and  likewise  serve  to  make  the  con- 
nection by  which  cutaneous  applications  influence  internal  parts. 


CHAPTER  VI 
THE  CIRCULATION-REFLEX  EFFECTS 

DURING  health,  there  are  vasomotor  influences  constantly 
playing1  upon  the  arteries  in  all  parts  of  the  body.  These 
influences  hold  the  vessels  in  "tone,"  i.  e.,  control  the  rhythmic 
oscillations  in  calibre,  so  that  blood  pressure  is  maintained. 
These  influences  seem  to  emanate  from  a  vasomotor  center 
which  is  located  in  the  medulla  oblongata  in  the  floor  of  the 
fourth  ventricle.  "  Irritation  of  this  center  causes  contraction 
of  all  the  arteries  and,  in  consequence,  increase  in  arterial 
blood  pressure."  "Paralysis  of  the  center  causes  relaxation 
and  dilatation  of  all  the  arteries,  with  enormous  reduction  in 
blood  pressure.  Under  normal  conditions  the  vasomotor  center 
is  in  a  state  of  moderate  tonic  excitation."  While  this  center 
exercises  a  controlling  influence  over  all,  it  is  not  the  only 
vasomotor  center.  "Centers  for  the  vascular  nerves,  both 
vasomotor  and  vasodilator,  are  distributed  throughout  the 
entire  spinal  axis."  (Plate  77.)  "  They  can  be  excited  reflexly, 
although  they  are  subordinated  to  the  dominating  centers  in 
the  medulla  oblongata."  2  "It  is  obvious  that  such  a  mechan- 
ism as  that  described  ...  is  susceptible  of  reflex  stimulation 
through  sensory  nerves,  and  according-  to  our  g-eneral  knowl- 
edge we  should  suppose  that  a  tonic  center  of  this  kind  may 
have  its  tonicity  increased  (excitation)  or  decreased  (inhibi- 
tion)." It  is  to  the  reflex  stimulation  of  these  centers  that 
we  now  wish  to  turn  our  attention,  for  through  this  channel, 
hydrotherapy  produces  some  of  its  most  important  effects. 

1  Landois— Physiology,  1905.  p.  762. 

2  Landois—  Physiology,  p.  735;  see  also  Howell— Physiology,  p.  564;  and  Foster— Physi- 
ology. 1898.  p.  285. 

3  Howell— Physiology,  p.  560. 

(62) 


PLATE  II.  Visceral  sympathetic  nerves.  Diagram  showing  the  areas  of  exit 
from  the  spine  of  the  sympathetic  nerves  controlling  the  various  organs  of  the  body. 
The  red  lines  in  the  table  indicate  vasomotor  areas.  Stimulation  of  the  centers  from 
which  these  sympathetic  nerves  originate  affect  the  organs  supplied  by  them.  (Pil- 
grim.) 


EXPERIMENTS  IN  REFLEX  EFFECTS  63 

Maximilian  Schiiller,4  in  experimenting-  on  trephined  rabbits, 
observed  that  severing-  single  nerve  trunks  on  one  side  of  the 
animal  produced  a  distinct  (though  transient)  dilatation  of  the 
pial  vessels  on  the  corresponding  .side,  thus  proving"  that  the 
blood-vessels  of  the  piamater  are  held  in  steady  tone  by  con- 
tinuous excitation  from  the  cutaneous  sensory  nerves.  This 
result  was  observed  only  on  the  side  of  the  severed  nerve  so 
that  it  could  not  have  been  due  to  shock  or  pain. 

Naumann  has  demonstrated  clearly  that  the  effects  of  ex- 
ternal irritants  upon  the  circulation  within  the  body  are  really 
reflex.  He  separated  the  head  of  a  frog  from  the  body, 
leaving-  them  connected  by  the  medulla  oblongata  only.  He 
next  severed  one  leg",  after  preventing-  loss  of  blood  by  tying- 
the  vessels,  so  as  to  leave  it  connected  with  the  body  by  the 
sciatic  nerve.  Now  he  applied  thermal,  chemical,  and  electric 
stimuli  to  the  foot  of  the  partially  severed  leg-,  while  he 
observed,  under  the  microscope,  the  mesentery  of  the  frog. 
Shortly  after  g-entle  irritation  of  the  peripheral  ending's  of  the 
sciatic  nerve  in  the  foot,  the  circulation  in  the  vascular  net- 
work of  the  lung's  and  mesentery  was  accelerated,  and  resumed 
the  former  condition  slowly  after  the  withdrawal  of  the  irritant. 
A  more  severe  irritation  produced  retardation  of  the  flow,  and 
even  stasis  occurred,  as  if  the  heart  had  become  temporarily 
paralyzed.  A  strong  irritant  produced  dilatation;  a  feeble  one, 
constriction  of  the  vessels.  The  effect  of  these  peripheral  irri- 
tations on  the  heart  was  also  noted.  A  strong-  irritation  of  the 
skin  weakened  its  circulation;  a  feeble  irritant  strengthened  it. 
As  there  was  no  possible  vascular  or  nerve  channel  from  the 
part  irritated  to  the  part  thus  visibly  affected,  the  conclusion  is 
inevitable  that  the  effect  is  entirely  reflex.  Hot  water  acted 
precisely  as  other  irritants."  These  experiments  also  prove 
that  there  are  two  reflex  means  by  which  the  circulation  may 
be  influenced,  viz.,  reflex  stimulation  of  the  vasomotors,  pro- 
ducing changes  in  vascular  calibre,  and  reflex  stimulation  of  the 
heart  muscle  itself.  Another  point,  brought  out  by  the  experi- 
ments of  Rohrig,  is  that  when  intense  cutaneous  irritants  pro- 


4  Deutches  Archiv  fflr  klinische  Medicin,  No.  4,  1874. 

5  Baruch— Principles  and  Practice  of  Hydrotherapy,  p.  37. 


64  REFLEX  EFFECTS 

duce  considerable  slowing-  of  the  heart  beat,  they  also  increase 
its  force.  This  is  the  effect  of  a  prolonged  cold  application, 
whether  general,  as  with  the  Brand  bath,  or  local,  as  with  the 
ice  bag  to  the  precordia. 

REFLEX  AREAS 

The  fact  of  reflex  stimulation  being;  established,  we  may  next 
consider  the  location  (topography)  of  the  various  reflex  areas. 
While  the  brain,  heart,  and  other  viscera  may  be  reflexly 
influenced  by  stimuli  applied  to  many  different  cutaneous  areas, 
some  even  very  remote  from  these  organs,  the  maximum  effects 
are  produced  by  stimulation  of  certain  very  definite  and  well 
recognized  areas.  In  general,  it  may  be  said  that  the  skin  over 
an  organ  is  reflexly  related  with  that  organ.  In  most  cases,  it 
is  not  difficult  to  trace  the  nerve  connection. 

"  In  general,  the  skin  overlying  an  organ  is  reflexly  associ- 
ated with  it,  which  is  the  reason  why  applications  of  electricity 
over  an  organ  usually  influence  it,  and  not  altogether  because 
the  current  is  passed  through  the  organ.  When  these  areas 
are  studied  comparatively,  it  is  noted  that  they  are  practically 
the  same  as  those  regions  pointed  out  as  showing  reflex  pain, 
which  would  suggest  a  nervous  path  from  the  organ  to  the  skin 
and  from  the  skin  to  the  organ,  the  terminations  of  which  are  in 
the  same  visceral  and  cutaneous  fields."  6  So  definite  and  cir- 
cumscribed are  some  of  these  areas  that  B.  G.  A.  Moynihan  has 
frequently  observed,  in  cases  of  duodenal  ulcer,  a  small  hyper- 
sensitive spot  in  the  skin  covering  the  abdomen,  directly  over 
the  ulcerated  area.  It  is  no  larger  than  a  six-pence  and  he 
attaches  much  value  to  this  phenomenon  in  differentiating  ulcer.7 

It  must  not,  however,  be  supposed  that  the  reflex  path  from 
the  viscera  to  the  skin  over  which  pain  is  referred  is  the  same 
path  as  that  utilized  in  therapeutics  for  reflex  effects  upon  the 
internal  organs.  Nor  are  the  skin  areas  to  which  pain  is 
referred  always  the  same  areas  that  should  be  utilized  to 

6  S.  D.  Ludlum— The  Relationship  between  the  Spinal  Cord,  the  Sympathetic  System 
and  Therapeutic  Measures— Journal  of  American  Medical  Association,  May  2,  1908    pp 
1401—1405. 

7  W.  D.  Haines— The  Differential   Diagnosis  of  Duodenal  Ulcer  and  Gall  Stones- 
Surgery,  Gynecology.  and  Obstetrics,  March,  1908,  p.  279. 


THE  REFLEX  ARC  65 

influence  reflexly  the  organ  in  which  the  cause  of  pain  is 
located.  For  example,  in  the  case  of  liver  and  gall-bladder 
disease,  there  is  frequently  a  pain  in  the  region  of-  the  right 
shoulder  or  shoulder  blade,  but  it  is  not  to  this  region  that 
applications  are  made  to  relieve  distress  due  to  hepatic  or  biliary 
affections. 

The  various  cutaneous  areas  to  which  the  pain  or  tenderness, 
due  to  visceral  disease,  is  referred,  are  spoken  of  as  the  derma- 
tomes  of  Head.  They  are  in  some  cases  of  considerable  service 
in  diagnosis  and  are  sometimes  serviceable  as  a  guide  in  the 
placing  of  therapeutic  applications.  They  can  not,  however, 
be  implicitly  relied  upon  for  either  purpose.  Relative  to  this 
unreliability  Abrams 8  says,  ' '  The  elicitation  of  the  dermatomes 
of  Head  is  a  tedious  method  of  examination  and  not  always 
accompanied  by  satisfactory  results  for  the  reason  that  a 
great  amount  of  experience  is  necessary.  Alsberg  in  the 
examination  of  two  hundred  women  (with  gynecological  affec- 
tions) found  cutaneous  areas  of  hyperalgesia  in  only  seventeen, 
ten  of  whom  were  hysterical.  Therefore,  he  could  attribute  no 
diagnostic  import  to  the  zones  in  question  beyond  commenting 
on  the  fact  that  hysterical  stigmata  must  be  excluded  before 
the  zones  of  hyperalgesia  could  be  regarded  as  trustworthy." 
Diagnosis  and  therapeutics  based  on  para-spinal  tenderness 
must,  therefore,  be  of  a  highly  imaginative  character  and  espec- 
ially so  when  approached  from  the  standpoint  of  a  prejudgment 
as  to  the  causes  of  disease  and  consequently  its  treatment. 

The  law  that  the  skin  over  an  organ  is  reflexly  related  with 
that  organ  may  be  regarded  as  an  amplification  of  Hilton's  law: 
The  principal  nerve  to  a  joint  not  only  supplies  the  articular  sur- 
faces but  also  some  of  the  main  muscles  that  move  that  joint  and  the 
skin  over  these  muscles.9  In  the  case  of  the  viscera,  however,  the 
deeper  part  of  the  reflex  arc  consists  of  a  sympathetic  neuron. 

THE  REFLEX  ARC 

The  reflex  arc  consists  of  several  parts  (Frontisplate  and  Fig. 
15.}.  In  general,  the  following  is  the  path  taken  by  a  stimulus 
arising  in  the  skin  from  a  thermic  application  and  traced  as  a 

8  Spondylotherapy,  p.  71. 

9  Treves— Applied  Anatomy,  1901,  p.  209. 

5 


66 


REFLEX  EFFECTS 


V.f: 


reflex  stimulus  to  the  organ  underlying  the  skin  surface  treated. 
From  the  skin  it  is  conveyed  by  a  sensory  (temperature)  nerve 
along  a  nerve  trunk  to  the  posterior  root  of  the  spinal  nerve; 
entering  the  posterior  root  ganglion,  where  the  fiber  is  seen  to 

be  the  distal  axon  of  a  T-cell, 
it  passes  on  through  the  cen- 
tral axon  of  the  T-cell  into  the 
posterior  side  of  the  spinal  cord. 
On  entering  the  cord,  the  fiber 
immediately  divides  into  an  as- 
cending and  descending  branch , 
both  located  in  the  posterior 
white  columns  and  which  give 
off  collaterals  to  the  gray  mat- 
ter.10 The  ones  we  are  con- 
cerned with  end  in  tufts  about 
the  cells  of  the  column  of  Clark. 
According  to  Starling, "  the 
vasomotor  center  in  the  me- 
dulla corresponds  in  position  to 
the  column  of  Clark  which  is 
doubtless  that  which  represents 
the  vasomotor  center  through- 
out the  rest  of  the  cord.  From 
these  cells,  axons  pass  either 
into  Gower's  tract  and  end  in 
the  cerebellum,12  or  pass  out  with 
the  anterior  root,  and  through 
the  white  ramus  to  the  ganglion 
of  the  lateral  sympathetic 
chain. 1S  Passing  directly  through 
this  or  up  or  down  through  an  adjacent  ganglion,  they  end 
in  a  peripheral  ganglion  from  which  the  viscus  is  supplied. 

The  fibers  of  the  white  ramus  which  pass  through  the  gang- 
lion and  go  to  the  periphery  are  known  as  the  splanchnic  efferent 

10  Whitaker— Anatomy  of  the  Brain  and  Spinal  Cord,  p.  38. 

11  Physiology,  p.  259. 

12  Ludlum -Journal  of  American  Medical  Association,  May  2,  1908,  p.  1403. 

13  Whitaker— Ibid,  p.  39. 


Fig.  15.  Diagram  to  show  path  of 
vasoconstrictor  fibers  from  vasoconstric- 
tor center  to  the  blood-vessels  and  the 
path  for  reflex  stimulation,  v.  c. — the 
vasoconstrictor  center,  1. — the  central 
neuron  of  the  vasoconstrictor  path,  2.— 
the  spinal  neuron  (preganglionic) ,  3. — 
the  sympathetic  neuron  (ganglionic) ,  a.— 
the  arteriole.  4.— the  sensory  fibers  of 
the  posterior  root  connecting  by  collater- 
als with  the  vasoconstrictor  center  and 
subcenters,  5.— fiber  from  cortical  cell 
acting  upon  the  vasoconstrictor  center. 
(Howell.) 


REFLEX  PATH  TO  HEART  -       67 

fibers,  and  constitute  the  secretory  fibers  of  the  splanchnic  glands 
and  the  motor  fibers  of  the  muscular  tissue  of  the  splanchnic 
blood-vessels  and  viscera."" 

By  studying  carefully  the  above  reflex  path,  it  will  be  noted 
that  a  stimulus  may  affect  (be  shunted  to)  cells  either  above 
or  below  {Fig.  15.}  the  level  at  which  it  enters  the  spinal  cord. 
And  again,  the  fiber  that  conveys  the  reflex  stimulus  to  the 
viscera  may  pass  up  or  down  in  the  gangliated  cord.  This  fact 
is  of  importance  in  explaining  why  cutaneous  nerves  are  con- 
nected reflexly  with  splanchnic  nerve  trunks  not  arising  in  the 
same  segment  of  the  cord.15 

Of  the  many  reflex  paths,  we  may  pick  out  two  as  serving  to 
quite  fully  illustrate  reflex  effects.  First,  let  us  study  the 
reflex  arc  concerned  in  the  effect  produced  by  an  ice  bag  applied 
to  the  precordial  region.  And  second,  the  arc  concerned  in  the 
reflex  between  the  skin  of  the  epigastrium  and  the  stomach. 

The  Heart.  Before  considering  the  reflex  arc,  we  should 
understand  that  the  heart  is  supplied  with  nerves  from  two 
sources.  {Plate  III.}  First,  through  the  vagus  nerve  (fibers 
of  accessory  part  of  the  spinal  accessory  nerve)  with  inhibitory 
fibers,  /<?.,  fibers  which  when  stimulated  slow  the  heart  beat 
and  increase  its  force.  Second,  by  accelerator  fibers,  which 
when  stimulated  increase  the  rapidity  of  the  heart  beat  through 
the  cardiac  sympathetic  nerves  from  the  inferior  cervical  gang- 
lion. The  accelerator  fibers  emerge  from  the  spinal  cord  in  the 
anterior  roots  of  the  second,  third,  and  fourth  thoracic  spinal 
nerves  and,  according  to  some  authors,  are  found  also  in  the 
first  and  fifth  thoracic  nerves.16  From  these  spinal  nerves  they 
pass  to  the  corresponding  sympathetic  ganglia  of  the  lateral 
chain  through  the  white  rami  communicantes,  and  thence 
upward  to  the  inferior  cervical  ganglion. 

The  ice  bag  applied  to  the  precordia  covers  the  skin  supplied 
by  the  second,  third,  fourth,  and  fifth  thoracic  nerves.  The 
stimulus  (of  a  depressing  nature),  produced  by  the  cold  applica- 


14  Gray's  Anatomy,  1905,  p.  1071. 

15  Each  segment  of  the  spinal  cord  may  be  regarded  as  a  unit  and  possessed  of  sensory, 
motor,   vasomotor,   secretory,  and  trophic  functions.    The  roots  and  peripheral  nerves 
derived  from  a  given  segment  are  an  integral  part  of  that  segment.      The  connection  of 
one  segment  with  another  does  not  interfere  with  this  conception. 

16  Howell— Physiology,  1908,  p.  542. 


68  REFLEX  EFFECTS 

tion,  is  carried  to  the  spinal  cord  by  the  nerve  fibers  of  these 
thoracic  nerves  which  end  in  the  same  segments  in  which  the 
accelerator  fibers  of  the  heart  arise.  (Frontisplate.)  The  reflex 
stimulus  produced  by  the  afferent  impulse  (sensation  of  cold) 
upon  the  cells  in  the  column  of  Clark  is  conveyed  outward -by 
the  axons  of  these  cells  through  the  anterior  roots  and  by  way 
of  the  white  rami  reaches  the  sympathetic  ganglia  through 
which  they  pass  to  the  inferior  cervical  ganglion,  and  thence  by 
the  inferior  (sympathetic)  cardiac  nerve,  to  the  deep  cardiac 
plexus  and  the  heart  muscle.  The  accelerator  mechanism  being 
depressed,  the  heart  beats  slower  and  with  greater  force  from 
the  proportionately  greater  action  of  the  inhibitory  nerves. 

An  ice  bag  over  the  heart  produces  its  action  by  depressing 
the  accelerator  (sympathetic)  nerves  and  not  by  stimulating  the 
vagus,  as  has  been  claimed  by  some;  which  latter,  it  will  be 
seen,  would  be  impossible,  since  the  prolonged  cold  of  the  ice 
bag  exerts  a  depressing  and  not  a  stimulating  effect,  which  latter 
must  be  the  case  were  slowing  produced  through  the  vagus. 

The  Stomach.  The  skin  over  the  pit  of  the  stomach  is  sup- 
plied by  the  seventh  and  eighth  intercostal  nerves.17  The  great 
splanchnic  nerve  is  formed  by  branches  from  the  thoracic  gang- 
lia between  the  fifth  or  sixth  and  the  ninth  or  tenth.  It  ter- 
minates in  the  semilunar  ganglion  of  the  solar  plexus.18  From 
the  solar  plexus,  (cceliac  part)  fibers  accompany  the  blood- 
vessels to  the  stomach. 

'  The  nerves  supplying  the  abdominal  muscles  and  the  skin 
are  derived  from  the  lower  intercostal  nerves  and  are  intimately 
connected  with  the  sympathetic  nerves  supplying  the  abdominal 
viscera  through  the  lower  thoracic  ganglia  from  which  the 
splanchnic  nerves  are  derived."  19 

These  reflex  arcs  may  be  traced  out  in  the  case  of  other  organs 
and  areas.  While  an  application  to  the  skin  over  an  organ 
gives  a  maximum  effect,  applications  to  even  very  distant  areas 
may  be  quite  effective.  For  example,  hot  applications  to  the 
feet  do  not,  under  ordinary  conditions,  influence  reflexly  the 
circulation  of  the  brain.  But  under  conditions  of  vasomotor 

17  Gray  s  Anatomy.  1905,  p.  997. 

18  Ibid.  p.  1079. 

19  Ibid.  p.  997. 


A  t  u^mffitor-  or 
Accelerator 


PLATK  III.     The  innervation  of  the  heart.     (Powell.) 


SPECIAL  REFLEX  AREAS  69 

instability,  such  as  that  following-  a  sunstroke,  a  hot  foot  bath 
may  cause  congestion  of  the  brain  (personal  observation). 

SPECIAL  REFLEX  AREAS 

The    following"   are    the  principal  reflex  areas  employed  in 
hydrotherapy  {Fig.  16.):  — 

1.  The  skin  areas  of  the  face,  scalp,  and  back  of  the  neck  are 
reflexly  related  with  the  brain. 

2.  The  skin  of  the  neck  is  reflexly  related  with  the  pharynx 
and  larynx. 

3.  The  back  of  the  neck  is  reflexly  related  with  the  mucous 
membrane  of  the  nose. 

4.  The   skin  of  the   chest   (front,   back,    and  sides),    dorsal 
region,  and  shoulders  has  reflex  relations  with  the  lungs. 

5.  The  precordia  is  in  very  perfect  reflex  relation  with  the 
heart  through  its  accelerator  nerves. 

6.  The  hands  are  related  with  the  brain  and  nasal  mucous 
membrane. 

7.  The  skin  over  the  lower  right  chest,  with  the  liver. 

8.  The  skin  over  the  lower  left  chest,  with  the  spleen. 

9.  The  skin  over  the  lower  third  of  the  sternum,  with  the 
kidneys  (Kellogg.). 

10.  The  mid-dorsal  spine  (from  fifth  to  seventh  vertebrae)  is 
related  with  the  stomach. 

11.  Lower  dorsal  and  lumbar  spine,   with  the    kidneys  and 
intestines. 

12.  The  lower  lumbar  and  sacral  spine,  with  the  pelvic  organs 
— uterus,  ovaries,  bladder,  and  rectum. 

13.  The  epigastrium,  with  the  stomach. 

14.  The  skin  of   the  entire  abdomen,  especially  that  of  the 
umbilical  region,  is  reflexly  related  with  the  intestines.     The 
fact  that  the  pain  of  colic,  appendicitis,  etc.,  is  referred  to  the 
region  of  the  umbilicus  is  an  evidence  of  a  similar  nervous  con- 
nection. 

15.  The  lower  abdomen,    including   the    groin    and  also   the 
upper  inner  surfaces  of  the  thighs  are  reflexly  related  with  the 
pelvic  organs. 

16.  The  skin  of  the  feet  and  legs  is  reflexly  related  with  the 


Brain 


Pelvic  Viscera 


Ovaries  and  Tubes 


,-  Brain,  Nasal  Mucous 
Membrane  and 
Lungs 


[-  Brain,  Lungs,  and 
'      Pelvic  Organs 


(70) 


Fig.  16.    Anterior  reflex  areas.    (Kellogg:.) 


SPECIAL  REFLEX  EFFECTS  71 

brain,   lungs,   and  pelvic  organs.     This  is  not  as  powerful  a 
reflex  area  as  some  others. 

More  practically  stated,  the  circulation,  secretory,  and  mus- 
cular activities  of  the  viscera  may  be  influenced  reflexly  by 
applications  as  follows: — 

1.  The  brain,  by  applications  to  the  head,  face,  back  of  neck, 
hands,  and  feet. 

2.  The  nasal  mucous  membrane,  by  applications  to  the  face, 
hands,  and  cervical  and  upper  dorsal  spine. 

3.  The  lungs,   by  applications   to  the    chest,    shoulders,   and 
dorsal  spine. 

4.  The  heart,  by  applications  to  the  Precordia  and  upper  dor- 
sal spine. 

5.  The  stomach,  by  applications  to  the  epigastrium  and  mid- 
dorsal  spine. 

6.  The  liver,  by  applications  to  the  lower  right  chest  and  the 
abdomen. 

7.  The  spleen,  by  applications  to  the  lower  left  chest  and  the 
abdomen. 

8.  The  kidneys,  by  applications  to  the  lower  third  of  the 
sternum,  lower  dorsal  and  lumbar  spine. 

9.  The  intestine,   by  applications  to  the  abdomen,  and  lower 
dorsal  and  lumbar  spine. 

10.  The  bladder,   by  applications  to  the  lower  abdomen,  inner 
surfaces  of  thighs,  and  the  feet. 

11.  The  uterus,    by   applications  to  the    lumbar   and   sacral 
regions,  lower  abdomen,  inner  surfaces  of  thighs,  breasts,  feet,  and 
cervix. 

In  the  large  majority  of  cases,  the  ventral  areas  give  stronger 
reflex  effects  than  the  dorsal  areas.  This  is  doubtless  for  the 
reason  that,  with  a  ventral  area,  the  effect  is  concentrated  upon 
a  single  organ,  while  in  the  case  of  a  dorsal  area,  limited  to  the 
region  of  the  spine  itself,  the  effect  would  be  spread  out  over 
several  organs,  or  possibly,  the  viscera  of  both  the  chest  and 
abdomen.  "  If  an  ice  bag  is  placed  in  contact  with  the  whole 
length  of  the  spine,  the  same  effect  on  the  heart  and  lungs  is 
produced  as  that  which  is  desired  on  the  intestines,  and  the 
whole  process  is  negatived,  whereas,  if  limited  anteriorally  to 


72  REFLEX  EFFECTS 

the    sixth    segment,   the   effect  is  localized  on  the  abdominal 
viscera." 

Definition  of  Reflex.  A  reflex  effect  is  then  an  indirect  effect 
produced  through  nerve  connection.  An  application  to  one 
part  of  the  body  which  influences,  through  nerve  connection, 
another  part  of  the  body  is  said  to  exert  a  reflex  effect. 
Abrams21  gives  the  following  definition:  "A  reflex  refers  to 
involuntary  production  of  activity  in  a  part  brought  about  by 
conduction  of  a  stimulus  along  an  afferent  (sensory)  nerve  to 
the  motor  cells  in  the  cord  or  medulla.  This  stimulus  is  con- 
verted into  an  impulse  by  the  motor  cells,  which  impulse  is 
then  conducted  to  a  part  by  means  of  an  efferent  (motor)  nerve. ' ' 

CLASSES  OF  REFLEX  EFFECTS 

Having  established  the  fact  of  reflex  action  and  traced  out 
some  of  the  reflex  arcs,  let  us  now  consider  the  nature  of  the 
various  reflex  effects.  We  have  already  noted  that  there  are 
three  kinds  of  fibers  which  make  up  the  splanchnic  efferents: 
•viz.,  the  secretory,  vis cero -motor ,  and  vasomotor.  These  are  also 
the  chief  functions  of  the  various  viscera  and  by  these,  meta- 
bolism itself  and  all  other  functions  are  controlled.  ' '  By 
applying  heat  or  cold  or  other  stimuli  to  the  segment  of  the 
skin  whose  endings  are  in  a  segment  in  which  arise  viscero- 
motor,  vasomotor,  or  other  activities,  we  can  reflexly  affect  the 
organ  supplied  by  these  tracts.  That  this  can  be  done  has 
been  shown  by  the  researches  of  Brown- Sequard  and  others, 
.  .  .  chiefly  through  the  vasomotors.  The  change  may  be 
observed  by  heat  and  cold,  impact  of  water,  hand  pressure 
(steady  or  alternated),  electricity,  mechanical  stimulation  or, 
other  means,  yet  the  underlying  principle  remains  the  same. 
The  application  of  these  physical  forms  of  therapy  must  be 
made  more  and  more  accurately  to  get  the  best  effect."  ^ 

There  are  two  general  classes  of  effects  produced  by  these 
applications.  They  may  be  designated  as  pressor  and  depressor, 
as  stimulant  and  calmative,  or  excitant  and  sedative.  Because 


S.  D.  Ludlum— Journal  American  Medical  Association,  May  2.  1908. 

21  Spondylotherapy,  p  26. 

22  S.  D.  Ludlum-- Ibid.  pp.  1403,  1405. 


SPECIAL  REFLEX  EFFECTS  73 

the  pressor,.  stimulant,  or  excitant  effects  are  usually  mild  and 
tend  to  restore  to  a  normal  tone,  they  are  frequently  designated 
as  tonic. 

SPECIAL  REFLEX  EFFECTS 

In  general,  the  reflex  effect  of  an  application  is  the  same  as 
its  direct  effect  upon  the  skin.  That  it  may  be  somewhat  less 
quantitatively  would  be  a  natural  result.  The  following  is  a 
comparison  of  the  direct  and  reflex  effects  of  prolonged  cold. 

1.  Direct  effects  upon  the  part  to  which  the  application  is 
applied, — 

(# )  The  blood-vessels  of  the  skin  or  mucous  membrane  are 
contracted. 

(£)  The  cutaneous  sensibility  is  lessened  and  reflex  excita- 
bility is  decreased  and  slowed  because  of  this. 

(c)  Glandular  activity  is  decreased. 

(d)  The  skin  muscles  are  contracted. 

2.  The  reflex  effects, — 

(a)  The  blood-vessels  of  the  deep  (internal)  organ  are  con- 
tracted and  remain  so. 

(£)  The  nerve  irritability  of  the  internal  organ  is  lessened. 

(<:)  The  glandular  activity  of  the  deep  part  is  decreased  and 
secretion  is  lessened. 

(d)  The  muscles  of  the  deep  organ  are  caused  to  con- 
tract more  firmly. 

The  reflex  effect  obtains  as  long  as  the  application  is  in  place 
and  for  a  variable  length  of  time  after  its  removal.  The  dur- 
ation and  intensity  of  reflex  effects  depend  upon  the  duration 
and  intensity  of  the  application.  The  vasoconstrictor  effects  of 
prolonged  cold  may  not  be  very  marked  in  health,  but  in  the 
case  of  a  congested  organ,  an  ice  bag  applied  to  the  reflex  area 
produces  an  astonishing  result. 

Special  Reflex  Effects  of  Prolonged  Cold.  A  long  {continu- 
ous') local  application  of  cold  causes  contraction  of  the  muscles 
and  decreases  the  vitdl  activities  of  the  surface  treated  and  the  inter- 
nal part  reflexly  related  therewith . 

1.  Cold  applied  over  the  trunk  of  an  artery  causes  contrac- 
tion of  the  artery  and  its  distal  branches.  (.Figs.  17  and  18.} 
Example, — ice  bags  applied  over  the  carotid  arteries  decrease 


7±  REFLEX  EFFECTS 

the  blood  going  to  the  brain  and  head  generally.  Such  an 
application  is  called  a  proximal  application,  since  it  is  located 
between  the  heart  and  the  part  supplied. 

2.  Prolonged  immersion  of  the  hands  in  cold  water  causes 
contraction  of  the  vessels  of  the  brain  and  nasal  mucous  mem- 
brane. 


Fig  17.  Sphygmographic  tracing  of  radial  pulse  showing  contraction  of  the 
vessels  of  the  forearm  resulting  from  application  of  ice  to  bend  of  elbow. 
(Kellogg.) 


Fig.  18.     Plethysmograph  tracing  showing  diminution  in  the  volume  of  the 
forearm  resulting  from  application  of  ice  to  elbow.     (Kellogg.) 

3.  Prolonged  cold  to  the  cervical  and  upper  dorsal  region 
causes  contraction  of  the  vessels  of  the  nasal  mucous  membrane 
and  lungs. 

4.  An  ice  bag  applied  to  the  precordia  slows  the  heart  rate, 
increases  its  force,  and  raises  arterial  blood  pressure. 

5.  An  ice  bag  applied  over  the  thyroid  gland  (in  parenchy- 
matous  goitre)  decreases  its  vascularity  and  lessens  its  glandu- 
lar activity. 

6.  Long  co!d  applications  to  the  chest,  at  the  back,  front,  or 
sides,  contract  the  blood-vessels  of  the  lungs,  {Figs.  19  and  20.) 
slow  respiration,  and  increase  its  depth. 


SPECIAL  REFLEX  EFFECTS 


7.-, 


7.  An  ice  bag  to  the  epigastrium  or  mid-dorsal  region  causes 
contraction  of  the  vessels  of  the  stomach  and  lessens  gastric 
secretion,  while  the  application  continues.28 

8.  A  long  cold  application  to  the  pelvis,  groin,  or  inner  sur- 
face of  the  thighs  contracts   the    blood-vessels    of   the  pelvic- 
organs. 

9.  A  long  cold  sitz  bath  causes  firm  contraction  of  the  uterine 
muscle,  thereby  reducing  subinvolution. 

10.  A  much  prolonged,  very  cold  application  to  the  sacrum, 
such  as  a  large  ice  bag,  dilates  the  blood-vessels  of  the  uterus, 
thus  increasing  menstrual  flow  and  inhibiting  pain.  This 

Skin 

\ 

Ice 

I  IX*  -^•"~  S 

Vaso 
^Vessels  of  th« 


\ 

Contracted  Vessels 
of  th«  Lung 


Fig.  19.    Diagram  showing 
congestion  of  the  lungs. 


Fig.  20.  Diagram  showing 
reflex  action  of  an  ice  bag  in 
decreasing  congestion  of  the 
lungs. 


paralyzes  the  reflex.  The  posterior  reflex  area  being  in  less 
perfect  relation  with  the  uterus  than  the  anterior  area,  makes 
this  possible. 

11.  Long  cold  applications  to  the  face,  forehead,  scalp,  and 
back  of  the  neck  cause  contraction  of  the  blood-vessels  of  the 
brain. 

12.  An  ice  bag  to  the  lower  third  of  the  sternum  or  over  the 
lower  dorsal  and  upper  lumbar  regions  causes  contraction  of 
the  blood-vessels  of  the  kidney. 

13.  Ice  bags  applied  to  the  sides  of  the  neck  just  below  the 
jaw  contract  the  blood-vessels  of  the  pharynx. 

23    See  experiments  by  Kasanski  in  chapter  on  peptogenic  effects. 


76  REFLEX  EFFECTS 

Special  Reflex  Effects  of  Short  Cold.  Short  cold  applications 
to  a  reflex  area  produce  tonic  and  stimulating  effects  in  the  deep 
part  by  virtue  of  the  reaction  which  soon  follows.  The  same  is 
true  of  alternating  applications  of  heat  and  cold. 

1.  Short  cold  applications  to  the    face  and  head   stimulate 
mental  activity. 

2.  A  short  cold  application  to  the  chest,  as  a  cold  rub,  fric- 
tion,  or  cold   douche,   at  first  increases  the  respiration  rate. 
Soon  it  results  in  deeper  respiration  with  a  somewhat  slowed 
rate. 

3.  A  cold  douche  to  the  precordia  or  slapping:  the  chest  with 
a  cold  towel  increases  both  the  heart  rate  and  force.     After  the 
cessation  of  the  application  the  rate  decreases,  while  the- force 
remains  increased. 

4.  A  short  very  cold  percussion  douche  to  a  reflex  area  causes 
active  dilatation  of  the  blood-vessels  in  the  related  viscera, — as 
a  short  cold  douche  to  the  sacrum  or  feet  causes  dilatation  of 
the  vessels  of  the  uterus. 

5.  Short  or  moderately  prolonged   cold  applications  to    the 
breasts  cause  vigorous  contractions   of  the  uterus — of  use  in 
inertia  uteri. 

6.  Short  very  cold  applications   to  abdomen,  hands,  or  feet 
cause  contraction  of  the  muscles  of  the  bladder,  bowels,  and 
uterus. 

7.  A  short  cold  douche  or  ice  bag-  intermittently  to  the  lower 
third  of  the  sternum  causes  increased  renal  secretion. 

8.  A  very  short  cold  douche  to  the  liver  causes  active  dilata- 
tion of  its  vessels  and  increases  its  glandular  activity. 

9.  The  reaction  from  a  moderately  prolonged  cold  application 
to  the  epigastrium  causes  increased  gastric  secretion.23 

Reflex  Effects  of  Hot  Applications. 

1.  A  very  much  prolonged  hot  application  to  a  reflex  area 
produces  passive  dilatation  of  the  blood-vessels  of. the  related 
organ. 

2.  Long  hot  applications  to  the  precordia  and  to  many  other 
parts  increase  the  heart  rate,   decrease  its   force,   and    lower 
blood  pressure. 


SPECIAL  REFLEX  EFFECTS  77 

3.  Hot  moist  applications  to  the  chest  facilitate  respiration 
and  expectoration. 

4.  Long,  moderately  hot  applications  over  the  stomach  after 
meals    increase    gastric   secretion  and  hasten  digestion.     The 
same,  if  given  before  a  meal,  decrease  gastric  secretion  because 
of  the  atonic  reaction  which  ensues. 

5.  Prolonged    hot    applications    to  the  abdomen  lessen  peri- 
stalsis, and  in  case  of  intestinal  colic,  relieve  pain  due  to  mus- 
cular spasm. 

6.  Prolonged  hot  applications  to  the  pelvis,  as  a  fomentation, 
hot  pack,  or  sitz  bath,  relax  the  muscles  of  the  bladder,  rectum, 
and  uterus  and  dilate  their  blood-vessels,  thus  relieving  tenes- 
mus  in  these  organs  and  increasing  the  menstrual  flow. 

7.  A  large,  hot  application  to  the  trunk,  as  a  hot  pack,  in 
biliary  or  renal  colic,  relaxes  the  muscles  of  the  bile  ducts,  gall 
bladder,  or  ureters  and  aids  in  relieving  the  pain  due  to  spasm 
of  these  muscles. 


CHAPTER  VII 
THE  CIRCULATION-HYDROSTATIC  EFFECTS 

NOT  all  of  the  circulatory  effects  occurring-  in  organs  and 
parts  distant  from  an    application    can  be  explained  by 
reflex  action.     In  fact,  many  of  the  effects  produced  by  hydri- 
atic  applications  are  quite  contrary  to  what  we  might  expect, 
were  the  results  due  alone  to  reflex  stimulation.    When  Schiiller, 
in  the  course  of  his  experiments  upon  trephined  rabbits,  placed 
a  sponge  dipped  in  cold  water  (52°  F.)  upon  the  trunk  of  a  peri- 
pheral nerve,  he  observed  narrowing  of  the  pial  vessels.     This 
was  the  same  result  as  that  obtained  by  pieces  of  ice  applied  to 
the  dura.     In  both,  there  was  vasoconstriction  of  the  vessels 
of  the  pia;  and  we  have  seen  that,  by  reflex  stimulation,  the 
same  effects  are  observed  internally  as  occur  externally  in  the 
skin  area  treated.     But  when  he  applied  to  the  belly  or  back  of 
the  rabbit  a  wet  compress  of  the  same  temperature,  it  always 
produced  a  prolonged  and  decided  dilatation  of  the  pial  vessels, 
just  opposite  to  the    effect    obtained    in    the   first  experiment 
quoted,   and  which  we  know  was  due   to  reflex   stimulation. 
Again,  he  found  that  the   application  of  *  warm  water  to  the 
nerve  trunk  produced  dilatation  of  the  vessels,   while  warm 
water  applied  to  the  general  skin  surface  by  immersion,  pro- 
duced a  narrowing  of  the  pial  vessels.     Since  these  effects  are 
directly  opposite,  both  can  not  be  explained  by  reflex  action. 
Moreover,  Schiiller  observed  that  immersion  in  warm  water  pro- 
duced a  more  decided  narrowing  of  the  vessels  than  a  warm 
compress;  and  immersion  in  cold  water,  a  more  decided  dilatation 
of  the  vessels  than  a  cold  compress.      These  effects  were  in  exact 
Proportion  to  the  extent  of  surface  immersed.     When  the  ears  of 
the  animal  were  kept  out  of  cold  water,  they  likewise  filled  with 

(78) 


HYDROSTASIS  AND  BLOOD  PRESSURE  79 

blood  in  common  with  the  pial  vessels,  but  when  they  were  also 
dipped  into  the  water,  the  vessels  of  the  pia  filled  still  more. 

The  explanation  of  these  contrary  effects  is  quite  obvious  and 
will  occur  to  anyone  acquainted  with  the  principles  of  hydro- 
statics. When  the  warm  compress  was  applied  to  the  animal, 
the  cutaneous  vessels  dilated,  thus  increasing  the  flow  of  blood 
to  and  amount  of  blood  in  the  skin  area  treated.  This  left 
less  blood  to  flow  to  the  brain  and,  in  consequence,  the  blood- 
vessels of  the  pia  were  less  completely  filled.  When  a  greater 
surface  was  treated,  as  by  immersion  in  warm  water,  a  greater 
number  of  blood-vessels  were  dilated  and  much  less  blood  left 
to  flow  to  the  head,  resulting  in  an  increased  narrowing  of  the 
pial  vessels. 

Considering  the  experiment  with  the  cold  compress  and  bath, 
we  have  the  same  underlying  principles.  The  cold  compress 
produced  blanching  of  the  skin  and  a  decreased  amount  of  blood 
in  the  periphery,  with  a  resulting  increase  in  the  filling  of  the 
blood-vessels  of  the  brain  because  of  retrostasis. 

Schiiller  observed  that  rectal  injections  of  cold  water  always 
produced  some  dilatation  of  the  vessels  of  the  pia.  These 
effects  have  been  confirmed  by  the  experiments  of  Vinaj, 
Naumann,  Winternitz,  and  others. 

That  these  results  are  hydrostatic  or  mechanical,  and  not 
reflex,  is  also  confirmed  by  the  changes  in  blood  pressure 
observed  at  the  same  time.  In  dilatation  of  the  blood-vessels 
due  to  vasomotor  action,  there  is  a.  fall  of  blood  pressure.  Quite 
the  opposite  occurred  when  the  pial  vessels  dilated  because  of  a 
cold  compress  or  cdld  immersion,  i.  e.,  a  decided  rise  in  arterial 
pressure.  This  we  know  is  associated  with  vasoconstriction 
and  can  not,  therefore,  be  due  to  paralysis  of  the  vasomotors. 
But  when  we  consider  that  the  cold  application  produced  blanch- 
ing of  the  skin  and  vasoconstriction  over  quite  a  large  area  and 
consequently  an  increase  in  blood  pressure,  the  whole  process 
is  quite  apparent.  The  retrostasis  and  increase  of  blood  press- 
ure causes  the  cerebral  vessels,  which  are  not  under  the  influ- 
ence of  the  cold,  to  fill  in  order  to  accommodate  the  blood. 

The  opposite  group  of  conditions  prevailed  with  the  hot 
application,  viz.,  narrowing  of  the  pial  vessels  with  a  fall  in 


80 


HYDROSTATIC  EFFECTS 


blood  pressure.  The  same  principles  apply  here  as  above, 
opposite  conditions  resulting-  from  opposite  causes.  The  hot 
bath  produced  afflux  of  blood  to  the  skin  through  vasodilatation, 
with  a  consequent  decrease  in  blood  pressure,  the  cerebral  ves- 
sels narrowed  because  of  a  relative  anemia.  If  the  narrowing 
of  the  pial  vessels  had  been  due  to  reflex  action,  there  should 
have  been  a  rise  instead  of  a  fall  in  blood  pressure. 

Schiiller  observed  that  prolonging-  the  warm  application  pro- 
duced an  increasing-  constriction  of  the  cerebral  vessels.  This 
may  be  explained  by  the  fact  that  a  passive  and  extreme  dilata- 
tion of  the  cutaneous  vessels  occurs  where  the  heat  is  main- 
tained for  a  long-  time.  This  is  the  effect  of  a  long-  hot  pack 
which,  in  practice,  we  utilize  where  decided  derivation  is 
desired. 


mmmmmKmm 

••mnsssan 
ssmmmmmmmmm 

••••••••m 


Fig.  21.    Volume  curve  of  right  arm  during  a  sitz  bath  at  110°  P.,  show- 
ing derivative  effect.     (Winternitz.) 

The  hydrostatic  effects  of  both  derivation  and  retrostasis  have 
been  demonstrated  by  Winternitz '  by  clinical  experiments.  By 
means  of  the  plethysmpgraph  he  determined  the  volume  curve 
of  the  forearm  during  a  hot  sitz  bath  and  also  during-  a  cold 
sitz  bath.  The  hydrostatic  results  are  graphically  shown  in 
Figs.  21  and  22.  The  cold  sitz  bath  caused  an  increase  in  the 
volume  of  the  forearm,  due  to  retrostasis,  consequent  on  contrac- 
tion of  the  vessels  under  the  influence  of  the  cold  water.  In 
the  case  of  the  hot  sitz  bath  the  blood-vessels  under  the  influence 

1     Winternitz— Physiologische  Grundlagen  der  Hydro   und  Thertnotherapie.  pp.  4.S.  44. 


SECONDARY  HYDROSTASIS 


81 


of  heat  dilated,  and  being-  more  completely  filled,  caused  a 
fall  in  the  volume  of  the  forearm  because  of  the  derivative  effect. 
Secondary  Hydrostasis.  When  the  cold  applications  were 
prolonged  Schiiller  observed  the  widening-  of  the  pial  vessels 
give  way  after  a  time  to  narrowing.  In  the  case  of  compresses 
this  change  occurred  after  two  or  three  minutes,  with  immersion 
after  five  to  ten  minutes.  It  is  apparent  to  all  that  a  cold  com- 
press, after  two  or  three  minutes,  becomes  a  heating  compress, 


BIPMH 
••••••(•nil 
•yarai 
•riH 


Fig.  22.    Volume  curve  of  right  arm  during  a  sitz  bath  at  50°  F.,  show- 
ing retrostatic  effect.     (Winternitz.) 

because  of  the  cutaneous  reaction  and  hence,  a  warm  compress, 
which  brings  about  the  narrowing  of  the  cerebral  vessels.  The 
same  is  true  of  the  cold  bath.  When  reaction  sets  in  the  skin 
becomes  reddened,  its  vessels  are  filled  with  blood,  and  the 
cerebral  vessels  contract.  This  secondary  hydrostatic  effect 
is  of  great  importance  in  the  practical  application  of  derivative 
means. 

A  hot  and  cold  percussion  douche  to  the  feet  reduces  cerebral 
congestion  because  of  blood  being  drawn  to  the  extremities  by 
the  reaction  in  the  feet. 

When  congestion  in  an  organ  has  been  reduced  by  a  hot  pack 
the  derivation  may  be  secured  (made  more  lasting)  by  com- 
pleting the  treatment  with  a  cold  mitten  friction,  thus  retaining 
the  blood  in  the  skin. 


gg  HYDROSTATIC  EFFECTS 

The  accompanying-  chart  summarizes  the  hydrostatic  effects 
of  heat  and  cold. 

Heat — draws  blood  to  the  surface — 
derivation 


The  Hydrostatic 
Effect  of 


Primary — drives  blood  to  the   in- 
terior— retrostasis 

Cold 

)   Secondary — draws  blood  to  the  sur- 

/  face — derivation 


Law  of  Antagonism.  These  hydrostatic  effects  are  well  recog- 
nized by  physiologists.  There  is  an  antagonism  between  the 
vessels  of  the  skin  and  viscera,  between  the  internal  and  ex- 
ternal vessels,  so  that,  when  the  periphery  is  well  filled,  there 
is  a  relative  anemia  of  the  viscera,  and  vice  versa.  The  so- 
called  Dastre-Morat  Law  of  Antagonism  is  thus  stated  by  Sir 
M.  Foster,2  "Moreover,  the  vascular  chang-es  in  the  skin  are 
accompanied  by  corresponding  vascular  changes  in  the  vis- 
cera (chiefly  abdominal)  of  the  reverse  kind.  When  the  vessels 
of  the  skin  are  dilated,  those  of  the  viscera  are  constricted,  and 
vice  versa;  so  that  the  blood  ebbs  and  flows,  so  to  speak,  accord- 
ing to  circumstances,  from  skin  to  viscera  and  from  viscera  to 
skin." 

These  mechanical  effects  are  necessarily  produced  solely  by- 
vascular  connection  and  not  by  nerve  connection.  A  reflex 
effect  is  an  indirect  or  distant  effect  produced  through  nerve  con- 
nection. A  hydrostatic  effect  is  a  distant  effect  produced 
through  vascular  connection.  The  extent  of  this  effect  de- 
pends upon  nothing  so  much  as  upon  the  extent  of  the  sur- 
face involved,  as  was  shown  by  the  experiments  with  the 
compresses  and  baths.  This  action  is  not  confined  to  the  blood 
•vascular  system,  but  applies  to  the  lymphatic  system  as  well. 
A  warm  application  which  causes  vasodilatation  will,  of  neces- 
sity, draw  blood  from  all  other  parts  of  the  body;  and  con- 
versly,  a  cold  application,  causing  vasoconstriction,  will,  in  the 
nature  of  the  case,  drive  the  blood  elsewhere,  principally  to  the 

2    Physiology,  p.  287. 


AREAS  FOR  DERIVATION  8S 

interior.  In  either  case  the  blood  is  driven  into  or  drawn  from 
the  deeper  parts.  In  the  normal  body  these  hydrostatic  effects 
are  more  or  less  evenly  distributed  over  the  entire  vascular 
system,  so  that  the  effect  in  any  one  part  is  not  so  marked. 
For  example,  a  hot  bath  or  pack  in  health  draws  the  blood  more 
or  less  equally  from  all  the  viscera;  but  in  case  of  congestion  of 
some  particular  organ,  that  organ  will  be  affected  more  than 
others  by  either  derivation  or  retrostasis.  A  common  example 
is  found  in  the  increase  of  pulmonary  congestion,  produced  by 
cold  drafts  on  the  shoulders.  In  a  healthy  person  this  might 
not  result  seriously,  but  in  one  susceptible  to  colds  or  with  an 
already  existing  congestion,  it  may  cause  an  extreme  congestion 
in  a  very  short  time.  In  the  same  condition  a  hot  pack  will 
draw  proportionately  more  blood  from  the  lungs  than  from  other 
parts.  Again,  a  large  fomentation  to  the  loins  or  a  hot  pack 
would,  under  normal  conditions,  withdraw  from  the  kidneys 
only  a  small  amount  of  blood;  but  when  these  organs  are  con- 
gested there  is  a  marked  depleting  effect  manifest.  The  patient 
is  bled  into  his  own  limbs  and  skin. 

Not  only  may  areas  quite  distant  from  a  part  be  utilized 
for  depleting  that  part,  but  in  many  cases  skin  areas  nearby 
may  be  used  to  advantage.  That  this  is  not  a  new  principle  in 
therapeutics  will  be  seen  by  referring  to  ' '  leech  ' '  bleeding. 
It  is  directed  that  the  leech  be  applied  to  the  skin  over  the  in- 
flamed part.  It  sucks  blood  from  the  superficial  branches  of 
the  same  vessels  that  supply  the  deeper  inflamed  part.  If,  by 
hot  applications,  the  arteries  of  the  superficial  set  of  branches 
be  widened  out,  there  will  be  less  blood  to  flow  into  the  deeper 
branches.  Thus  will  a  fomentation  draw  blood  from  a  part 
nearby  that  receives  its  blood  from  the  same  large  artery. 
Where  there  are  large  thick  muscles  under  the  skin  area  treated 
the  total  vascular  capacity  of  both,  when  filled  to  the  limit,  may 
produce  a  very  decided  derivation. 

AREAS  FOR  DERIVATION 

The  various  viscera  are  mechanically  related  to  superficial 
and  other  areas  as  follows.  In  most  cases  these  areas  are 
utilized  for  depleting  (derivative)  effect,  but  the  opposite  con- 
dition (retrostasis)  may  obtain  where  these  areas  are  chilled. 


S4  HYDROSTATIC  EFFECTS 

1.  The  Brain.     Blood  may  be  withdrawn  from  the  brain  by 
•  hot  applications-  to  the  feet,  legs,  or  entire  lower  limbs,  also  to 

the  spine  or  entire  surface  of  the  trunk.  It  is  not  practical  to 
utilize  the  emissary  veins  of  the  cranial  circulation  for  this  pur- 
pose, since  the  reflex  effect  in  dilating-  the  cerebral  vessels 
would  be  greater  than  the  depleting  effect.  In  cases  of  severe 
sunstroke  the  vasomotors  are  so  unbalanced  that  even  a  hot 
foot  bath  may  reflexly  produce  cerebral  congestion  rather  than 
depletion,  and  must,  therefore,  be  avoided. 

2.  Spinal  Cord.     Congestion  here,  if  not  too  extreme,  may 
be  relieved  by  large  fomentations  to  the* spine  (entire  width  of 
the  back).     This  diverts  the  blood  from  the  spinal  arteries  into 
the  posterior  divisions  of  the  intercostal  and  lumbar  arteries, 
also  by  hot  applications  to  the  feet,  legs,  or  the  skin  surface  of 
the  trunk.     In  cases  of  acute  cerebro-spinal  meningitis  it  is 
best  to  utilize  the  more  distant  areas. 

3.  Eye.     Applications  may  be  made  to  the  forehead  and  side 
of   the    face,   thus    dilating    some    of   the    terminal    superficial 
branches  of  the  carotids,  and  depleting  the  deeper  branches. 

4.  Middle  Ear  and  Mastoid.     By  applications  to  the  entire 
side  of  the  head,   also  by  very  hot  applications   to  the   legs, 
abdomen,  and  spine. 

5.  Pharynx  and  Larynx.     By  applications  to  the  neck,  thus 
depleting  the  deeper  organs  and  congesting  the  surface  vessels. 

6.  Lungs.     The   feet  and  lower  limbs,   skin  surface  of  the 
trunk  and  hips,  also  the  hands,  arms,  and  shoulders.     Where 
the  congestion  is  limited  to  a  small  area,  as  in  circumscribed 
pleurisy,  a  fomentation  may  be  used  directly  over  that  area. 
This    dilates    the    posterior,    lateral,    and    anterior   cutaneous 
branches  of  the  intercostal  arteries,  thereby  withdrawing  blood 
from  the  inflamed  pleura. 

7.  Kidneys.     The  circulation  in  these  organs  is  decreased  by 
hot  applications  to  the  back,  thus  dilating  the  posterior  branches 
of  the  lumbar  and  lower  intercostal  arteries,  and  leaving  less 
blood  to  pass  from  the  aorta  to  the  renal  arteries.     In  extreme 
congestion  of  the  kidneys  it  is  necessary  to  utilize  much  larger 
areas,  as  the  entire  surface  of  the  trunk,  hips,  and  legs,  or  one 
of  these  areas  alone. 


AREAS  FOR  DERIVATION  85 

8.  Stomach.     By  large  applications  centering-  at  the  epigas- 
trium,  but  extending  over  the  lower  chest  and  sides  of  the 
abdomen  and  well  down  over  the  umbilical  region,  also  to  the 
entire  trunk. 

9.  Liver.     By  applications  over  the  liver  also  to  the  lower 
dorsal  spine  of  the  right  ride,  extending  forward  and  covering 
the  epigastric    and  umbilical  regions.     The  skin  area  of  the 
lower  limbs  and  hips  is  as  important,  if  not  more  so,  than  the 
nearer  areas. 

10.  Spleen.     Similar  to  the  liver,  on  the  opposite  side,   also 
lower  limbs. 

11.  Pelvic   Organs — bladder,   uterus,   ovaries,   tubes,  rectum, 
and  prostate.     To  deplete  these  organs  two  principal  areas  are 
utilized, — first,  the  entire  skin  surface  of  the  hips,  pelvis,  etc., 
as  in  a  hot  sitz  bath  or  hot  hip  pack;  second,  the  lower  limbs, 
as   in  a  hot  leg  bath  or  hot  leg  pack.     Both  areas   may  be 
utilized  by  the  use  of  the  hot  hip  and  leg  pack  or  hot  half  bath. 

The  student  who  is  familiar  with  the  anatomy  of  the  circula- 
tory system  will  be  able  to  figure  out  the  vascular  connections 
between  the  organs  mentioned  above  and  areas  named  with 
each.  In  nearly  every  case  it  is  quite  obvious.  These  areas 
are  of  importance,  not  alone  in  ordinary  congestion,  but  of 
almost  inestimable  service  in  actual  inflammation  of  these  parts, 
as  shown  later.  (See  treatment  of  inflammations.) 


CHAPTER   VIII 

THE  CIRCULATION -BALANCE  BETWEEN 
REFLEX  AND  HYDROSTATIC  EFFECTS 

BY  reference  to  the  observations  recorded  under  reflex  and 
hydrostatic  effects,  it  will  be  seen  that  thermic  applications 
to  the  surface  exert  two  classes  of  effects — a  reflex  and  a  hydro- 
static effect — which  are  directly  opposite  and,  therefore,  con- 
flicting. Probably  an  application  produces  more  or  less  of  both, 
though  one  or  the  other  usually  predominates.  Since  they  are 
opposite,  one  will  neutralize  or  overshadow  the  other.  Kellogg  ' 
makes  the  following  statement:  "Doubtless  both  of  these 
effects  are  always  produced.  When  the  application  is  general 
the  mechanical  effect  is  dominant;  when  the  area  involved  is 
limited,  the  reflex  effect  is  prominent.  In  general  applications, 
the  primary  reflex  effect  is  quickly  effaced  by  the  succeeding 
mechanical  effect,  due  (in  case  of  cold)  to  the  inrush  of  blood 
from  the  periphery.  This  diversion  of  blood  from  the  surface 
vessels  to  the  interior  of  the  body  is  termed  retrostasis. 
Marked  retrostasis  is  produced  only  when  the  cold  application 
is  made  simultaneously  to  a  very  large  cutaneous  area. ' '  These 
are  essentially  the  views  of  Schiiller,  who  considered  that,  at 
the  beginning  of  the  application,  the  pial  vessels  were  affected 
reflexly,  which  effect  is  soon  overbalanced  by  the  thermic  effect 
upon  the  vessels  of  the  skin. 

"If  the  surface  area  to  which  the  application  is  made  is  small, 
the  reflex  effect  may  be  confined  to  the  internal  area  in  sympa- 
thetic relation  therewith,  and  will  be  greater  and  more  prolonged 
for  the  reason  that  the  reflex  influence  is  concentrated  upon  a 
circumscribed  area;  while  the  mechanical  effect  is  distributed 
over  the  rest  of  the  body,  so  that  it  does  not  overshadow  and 

1     Hydrotherapy.  p.  103. 
(86) 


LA  WS  OF  BALANCE  87 

wipe  out  the  reflex  effect  on  the  smaller  area  involved." 
Baruch's  comment2  upon  this  subject  is  as  follows:  "Baths 
and  other  procedures  without  mechanical  excitation,  when 
applied  to  large  portions  of  the  body,  doubtless  have  a  hydro- 
static effect;  while  douches,  which  impinge  on  limited  portions, 
and  are  combined  with  mechanical  effects  (irritation),  act 
chiefly  by  reflex  influence." 

Is  it  possible  to  determine  which  result  will  be  greater  in  a 
given  case,  or  which  will  be  practically  the  only  effect  from  a 
certain  application?  In  reply  to  this  very  natural  question,  we 
may  state  that  there  are  definite  laws  governing  these  oppos- 
ing actions.  By  them  one  may  so  time  and  regulate  applica- 
tions as  to  secure  a  desired  and  definite  result. 

LAWS  OF  BALANCE 

The  following  are  the  laws;  other  things  being  equal,  the 
results  stated  obtain: — 

1.  Size  of  Area,     (a)  When  an  application  covers   a  small 
area  the  effect  is  chiefly  reflex,  and  is  concentrated  upon  the 
internal  part  in  reflex  relation  with  the  surface  treated. 

(b)  When  applications  are  made  to  a  large  area  the  hydro- 
static effect  predominates,  and  the  larger  the  area  treated  the 
greater  the  hydrostatic  effect. 

2.  Location  of  Area,     (a)  The  chief  effect  of  an  application 
to  certain  areas  (example,  the  head  or  the  precordia)  is  a  reflex 
effect. 

(b)  The  principal  result  of  an  application  to  certain  other 
areas  (example,  the  feet  and  legs)  is  hydrostatic. 

Duration  and  Intensity  of  Application.  The  duration  and  in- 
tensity of  the  effect,  either  reflex  or  hydrostatic,  depend  upon 
the  duration  and  intensity  of  the  application.  The  intensity 
of  an  application  is  gauged  by  the  degree  of  heat  or  cold  and 
by  the  form  and  pressure  of  douches,  or  the  degree  and  amount 
of  friction. 

Examples:  The  prolonged  application  of  an  ice  bag  (small 
application  of  intense  cold)  to  the  precordia  (special  area)  pro- 
duces a  (reflex  effect)  prolonged  slowing  of  the  rate  of  the  heart 
beat,  and  a  decided  increase  in  its  force  for  the  same  length  of 

2     Principles  and  Practice  of  Hydrotherapy,  p.  48. 


88  BALANCE  IN  CIRCULATORY  EFFECTS 

time.  There  is  no  tendency  to  produce  retrostasis  of  blood  or 
engorgement  of  the  heart  (hydrostatic  effect) . 

A  hot  trunk  pack  (large  area)  withdraws  blood  from  the  vis- 
cera (hydrostatic  effect)  rather  than  producing-  dilatation  and 
engorgement  of  their  vessels  (reflex  effect). 

A  hot  and  cold  douche  to  the  chest  (small  intense  applica- 
tion) stimulates  the  heart  and  respiration  (reflex  effect)  rather 
than  having  any  decided  hydrostatic  effect  upon  the  blood  cur- 
rent of  these  organs.  Applications  to  the  head  (special  area), 
whether  hot  or  cold,  have  a  reflex  effect  almost  entirely. 

Many  other  examples  might  be  given,  but  the  principles  in- 
volved in  the  above  are  the  same  as  those  which  govern  other 
applications.  It  will  be  seen  that,  although  reflex  and  hydro- 
static effects  directly  oppose  each  other,  the  reflex  overshadows 
and  obliterates  the  hydrostatic  when  certain  areas  are  involved, 
and  especially  when  these  areas  are  small.  The  hydrostatic  effect 
wipes  out  the  reflex  effect  when  the  application  is  to  certain 
other  areas,  and  especially  when  those  areas  are  very  large. 

We  have  so  far  discussed  these  two  classes  of  effects  as  to 
their  opposing  results.  Reflex  and  mechanical  effects  may  be 
made  to  assist  each  other  in  securing  depletion  when  diverse 
applications  are  made  to  different  areas  simultaneously.  This 
will  be  discussed  under  the  head  of  derivation.8 

Double  Effects.  In  the  case  of  hot  applications  applied  over 
congested  organs,  certain  phases  of  both  the  reflex  and  the  hy- 
drostatic effect  may  prevail.  This  is  expecially  noticeable 
with  large  fomentations  or  hot  packs  over  the  liver  or  kidneys. 
These  reflexly  relax  (and  dilate)  the  blood-vessels  of  the  in- 
ternal organ  while  hydrostatically  they  draw  blood  from  the 
organ  thus  leaving  the  vessels  of  that  organ  relaxed  but  only 
partially  filled  with  blood,  /.  <?.,  partly  collapsed.  This  double 
effect  from  a  single  application  is  of  great  importance  in  acute 
congestions  of  the  kidneys  and  liver  as  in  eclampsia  where  vas- 
cular tension  is  high  but  the  organ  functionally  inactive.  The 
tension  being  relieved  by  relaxation  of  the  muscular  coat 
(reflexly)  and  the  congestion  depleted  (hydrostatically),  the 
blood  again  circulates  more  rapidly  and  functional  activity 
begins  almost  at  once. 

3    See  chapter  on  inflammation  and  antiphlogistic  effects. 


CHAPTER  IX 
THE  CIRCULATION -BLOOD  PRESSURE 

IN  order  that  the  reader  may  grain  a  practical  knowledge  of 
therapeutic  effects  upon  abnormal  blood  pressure,  we  shall 
discuss  somewhat  at  length  the    fundamentals  of  this  subject 
and  of  thermic  applications  on  normal  blood  pressure. 

Blood  pressure  is  governed  by  the  following  three  factors:  — 

1.  The  heart  beat. 

2.  The  .amount  of  blood. 

3.  Vascular  calibre  and  action. 

1.  The  Force  of  the  Heart  Beat,  its  rapidity,  and  the  volume 
of  its  output  are  secondarily  influenced  by  the  other  two  factors. 
So  closely  related  are  these  three,  that  practically  one  can  not 
be  studied  without  studying  the  other  two.  Influences  which 
bring  about  a  change  in  any  one  of  these  factors,  produce 
through  that  factor  a  change  in  the  remaining  two.  For  ex- 
ample, an  increase  in  the  peripheral  resistance  increases  the 
output  and  volume  of  the  ventricles.  (Fig.  23.)  Within  certain 
limits  an  increase  in  the  volume  of  the  circulating  fluid  likewise 
increases  the  output  and  volume  of  the  ventricles.  (Fig.  24.} 

General  hot  baths,  such  as  hot  air,  electric  light,  Russian, 
and  full  hot  tub  baths,  increase  the  heart  rate  and  decrease  its 
force.  This  is  due  to  reduction  in  the  peripheral  resistance 
occasioned  by  the  extensive  vasodilatation  which  is  itself  the 
direct  cause  of  the  lowered  blood  pressure.  General  cold  baths, 
or  even  fair  sized  cold  applications,  increase  blood  pressure 
because  of  the  resulting  vasoconstriction. 

Those  things  which  directly  affect  the  heart  beat  come 
.principally  through  reflex  stimulation.  All  sorts  of  cold  appli- 
cations to  the  precordia  increase  the  muscular  contractions  and 

(89) 


_j 
<L>  —  O 

~V° 

Hi 

•-    C    — 


i  F  - 
s| 


il 


iill 


•  c  c.2 




.§2 
P 


(90) 


CIRCULATING  FLUID 


91 


so  raise  blood  pressure.     After  a  brief  rise,  hot  applications  to 
the  precordia  decrease  blood  pressure.     Short  cold  applications 
to  the  precordia  increase  the  heart  rate,  while  long-  cold  appli- 
cations   decrease 

••••••••••1      the  heart  rate.     In 

the  normal  person 
both  results  are 
associated  with  a 
rise  in  blood  press- 
ure. Rapidly  alter- 
nating hot  and 
cold  applications  to 
the  precordia  have 
much  the  same  ef- 
fect as  short  cold 
applications,  ex- 
cept that  the  stimu- 
lation ,  being-  great- 
er, causes  a  great- 
er rise  in  blood 
pressure.  This 
rise  is  less  perma- 
nent than  that  ac- 


companying' pro- 
longed cold  appli- 
cations to  the  pre- 
cordia. These 
points  have  been 
thoroughly  dis- 
cussed elsewhere. 

2.  The  Amount  of  the  Circulating  Fluid.  An  increase  in  the 
quantity  of  blood  in  the  vascular  system,  other  thing's  being- 
equal,  increases  blood  pressure.  In  order  to  intelligently  apply 
those  therapeutic  measures  which  are  designed  to  maintain 
blood  pressure  through  changes  in  the  amount  of  the  circulat  - 


Fig.  24.  Cardiometer  tracing  from  a  dog's  heart 
showing  effect  of  increasing  the  volume  of  circulat- 
ing fluid  on  the  total  output  and  volume  of  the 
heart.  Between  the  parts  A  and  B  30  c.  c.  of  warm 
physiologic  salt  solution  were  injected  intraven- 
ously, and  between  B  and  C  20  c.  c.  more.  Both  the 
systolic  and  diastolic  volume  are  increased,  i.  e.,  the 
heart  is  more  distended  during  diastole,  and  does 
not  contract  to  its  normal  size  in  systole.  The  re- 
sult is  a  very  largely  increased  output.  (Roy.) 


;,j  BLOOD  PRESSURE 

ing  fluids,  it  is  necessary  to  obtain  an  understanding  of  the 
laws  governing  the  intake  and  output  of  body  fluids  and  also 
the  absorption  of  extra- vascular  tissue  fluids.  Modern  knowl- 
edge of  the  fluids  of  the  body  has  been  summarized  by  E.  H. 
Starling:.1  From  this  source  we  have  drawn  much  of  the  fol- 
lowing: information. 

The  absorptive  membranes  of  the  body  possess  a  discriminat- 
ing: or  irreciprocal  permeability  to  fluids,  /.  e.,  fluids  containing 
certain  saline  substances  are  readily  and  rapidly  absorbed, 
while  fluids  containing-  other  salts  are  either  not  absorbed,  or 
only  after  long  contact. 

"  If  the  solutions  contain  sulphates  or  tartrates,  i,  <?.,  salts  to 
whose  anions  the  gut  wall  is  relatively  impermeable,  the  course 
of  events  is  very  much  the  same  as  that  which  would  occur  if 
these  solutions  were  separated  from  blood  plasma  by  a  dead 
wall  of  parchment  paper.  If  they  are  hypertonic  they  increase 
in  amount  by  the  attraction  of  water  from  the  circulating  fluids, 
until  their  molecular  concentration  is  equal  to  that  of  blood 
plasma."  By  long  contact  they  are  finally  absorbed.  "  Very 
different  is  the  fate  of  solutions  of  substances  such  as  sodium 
chloride.  These  are  rapidily  absorbed  even  when  they  are 
slightly  hypertonic.  If  the  solutions  are  strong,  i.  e.,  two  or 
three  per  cent  NaCl,  they  at  first  increase  in  bulk  by  the  dif- 
fusion of  water  into  them.  From  the  moment  of  their  intro- 
duction, however,  salt  is  passing  from  them  into  the  blood, 
circulating  through  the  intestinal  wall,  and  as  soon  as  their  total 
osmotic  pressure  is  reduced  to  a  point  a  little  above  that  of  the 
blood  plasma,  .both  water  and  salt  begin  to-be  absorbed."  3 

This  selective  action  is  found  to  depend  upon  the  vitality  of 
the  cells  composing  the  membrane,  since  it  ceases  when  the 
cells  have  been  damaged  by  certain  chemicals.  The  fate  of 
fluid  introduced  into  the  gut  then  seems  to  depend  entirely  upon 
its  concentration.  The  epithelial  cells  composing  the  mucous 
membrane  of  the  intestine  possess  the  power  of  pumping  water 
and  salts  from  one  side  of  the  cell  to  the  other.  ' '  This  con- 


1  Herter  Lectures,  New  York,  1908. 

2  Starling— The  Fluids  of  the  Body,  p.  53. 

3  Ibid.  p.  53. 


ABSORPTION  OF  FLUID  93 

elusion  is  confirmed  by  certain  experiments  of  Reid  and  Cohn- 
heim,  in  which  two  identical  solutions  of  sodium  chloride  were 
separated  from  one  another  by  a  membrane  consisting-  of  the 
whole  living'  intestinal  wall.  In  these  experiments  it  was 
found  that  there  was  active  transference  from  the  inner  to  the 
outer  side  of  the  membrane."  The  same  was  found  to  hold 
true  with  the  skin.  When  brought  in  contact  with  deleterious 
substances,  the  cells  of  the  skin  behaved  like  ordinary  dead 
membrane,  the  irreciprocal  permeability  and  the  active  trans- 
ference of  fluid  totally  disappearing1. 

SaHne  solutions,  somewhat  less  in  concentration  than  blood 
serum,  are  very  rapidily  absorbed  from  the  intestine,  somewhat 
more  so  than  even  isotonic  solutions.  The  rapid  absorption  of 
hypotonic  or  isotonic  solutions  introduced  into  the  bowel,  is 
then  shown  to  be  due  to  the  specific  activity  of  the  epithelial 
cells,  aided  by  the  greater  osmotic  pressure  of  blood  serum  in 
the  case  of  hypotonic  solutions.  The  ready  and  constant  absorp- 
tion of  fluid  which  occurs  with  the  Murphy  method  of  entero- 
clysis  is  a  most  effectual  means  of  maintaining"  blood  pressure 
at  an  even  point.  In  case  of  much  loss  of  fluid  or  lowering:  of 
blood  pressure,  after  a  fairly  normal  amount  of  fluid  and  degree 
of  blood  pressure  has  been  secured  by  the  absorption  of  the 
saline  fluid,  the  salt  solution,  if  injected  slowly,  is  eliminated 
by  the  kidneys  at  the  same  rate  at  which  it  is  absorbed.5 

The  laws  of  osmosis  when  working  in  connection  with  the 
intestinal  wall  above  referred  to,  account  for  the  hydrogogne 
action  of  hypertonic  solutions  of  such  substances  as  Epsom 
salts,  Rochelle  salts,  and  honey,  when  injected  into  the  bowel. 
Strong"  solutions  of  these  substances  cause  an  exosmosis,  /.  e., 
when  they  remain  a  comparatively  short  time  water  is  drawn 
from  the  circulating"  fluid  and  increases  the  bulk  of  the  injected 
fluid.  This  "washing""  through  the  mucous  membrane  clears 
it  of  mucus,  helps  dislodge  mucous  casts,  etc.  These  observa- 
tions furnish  a  rational  basis  for  the  use  of  the  hypertonic  saline 
enema,  and  the  honey  or  molasses  enema,  in  mucous  colitis. 

In  regard  to  the  absorption  of  interstitial  fluids,  and  of  fluid 


4  Starling— The  Fluids  of  the  Body,  p.  57. 

5  Ibid,  p.  139 


94  BLOOD  PRESSURE 

introduced  by  hypodermoclysis,  Starling-  concludes  that  this 
occurs  mostly  by  the  blood  rather  than  the  lymphatics,  as  has 
long-  been  supposed.  Indigo,  carmine,  or  methylene  blue  in- 
jected into  the  pleural  or  peritoneal  cavities,  may  appear  in  the 
urine  within  six  minutes  after  the  moment  of  injection  at  a 
time  when  the  lymph  in  the  thoracic  duct  is  free  from  color. 
Strychnine  or  other  drug-  injected  under  the  skin  of  a  limb 
exerts  its  poisonous  effects  on  the  nervous  system  long  before 
the  drug  itself  appears  in  the  lymph  flowing  from  the  limb. 
It  has  been  shown  that  blood  returning  from  an  edematous 
limb  is  more  dilute  than  blood  returning  from  a  normal  limb. 
The  experiment  conducted  by  Starling6  is  as  follows:  By  means 
of  cannulas  inserted  into  the  femoral  artery  and  vein,  defibrin- 
ated  blood  of  the  same  osmotic  pressure  as  normal  blood  serum, 
was  caused  to  pass  through  the  arteries,  capillaries,  and  veins 
of  the  normal  leg  of  a  dog.  The  same  was  done  with  the 
opposite  leg  made  edematous  by  the  injection  of  a  one  per  cent 
solution  of  NaCl.  Blood  which  had  been  led  through  the  nor- 
mal leg  twelve  to  twenty-five  times  was  unaltered  or  suffered 
trifling  change,  while  that  led  the  same  number  of  times 
through  the  edematous  leg  had  in  all  cases  absorbed  fluid. 
From  these  experiments  we  may  affirm  with  certainity  that 
isotonic  salt  solutions  can  be  taken  up  directly  by  the  blood 
circulating  in  the  blood-vessels."7  Hypodermoclysis  is  the 
most  rapid  method  (aside  from  direct  vein  injection)  of  intro- 
ducing fluid  into  the  circulation.  Increase  in  the  amount  of 
fluid  in  the  vascular  system  results  in  heightened  venous  press- 
ure, which,  in  turn,  produces  an  increase  in  diastolic  filling, 
systolic  output  and  arterial  pressure,  and  greatly  hastens  the 
velocity  of  the  circulation.  (Fig.  24.)  "  Blood  with  its  lower 
viscosity  passes  readily  through  the  dilated  arterioles  and  cap- 
illaries, so  that  the  velocity  of  the  blood-flow  may  be  easily 
increased  from  six  to  ten  times."8  Injecting  salt  solution 
equivalent  to  50  per  cent  of  the  total  blood  has  been  found  to 
augment  the  velocity  of  the  blood  six  to  eight  times  the  normal 
rate.9 

6  Starling— The  Fluids  of  the  Body  p  95 

7  Ibid,  p.  97. 

8  Ibid.  p.  138. 

9  Starling— Physiology,  p.  284. 


VASCULAR  CALIBRE  AND  ACTION  95 

The  rise  in  blood  pressure  occasioned  by  the  absorption  of 
fluid  introduced  by  either  hypodermoclysis  or  proctoclysis  is  of 
special  advantage  in  various  conditions  where  the  blood  press- 
ure has  fallen  very  low,  such  as  in  collapse  (after  hemorrhage), 
in  peritonitis,  etc.  The  Murphy  method  of  proctoclysis  is  espec- 
ially recommended  in  the  treatment  of  peritonitis  after  the  in- 
stitution of  surgical  drainage.  It  is  designed  to  flush  the 
drained  surfaces,  and  so  aid  in  getting  rid  of  septic  material 
and  infection.  We  believe  its  beneficial  action  is,  however, 
due  as  much  to  the  maintenance  of  blood  pressure,  as  to  the 
flushing  of  the  absorbents  and  drained  surfaces. 

Given  in.  the  order  in  which  they  most  rapidly  increase  the 
volume  of  the  blood,  the  methods  of  introducing  fluid  into  the 
circulatory  system  may  be  listed  as  follows: — 

(a)  Hypodermoclysis. 

(b)  Proctoclysis. 

(c)  Water-drinking. 

3.  Vascular  Calibre  and  Action.  We  have  seen  that  a  hot 
application  dilates  the  blood-vessels,  producing  an  afflux  of 
blood  to  the  skin  and  superficial  parts,  increasing  with  the 
prolongation  of  the  application.  It  has  also  been  shown  that 
the  reaction  to  a  cold  application  produces  an  afflux  of  blood 
to  the  skin.  In  both  cases  there  is  a  hyperemia  established, 
but  the  two  are  of  an  entirely  different  nature.  With  the 
hot  application  there  is  a  fall  of  blood  pressure  because  of  a 
loss  of  tone  in  the  vessels  (passive  dilatation)  and  a  prepon- 
derance of  venous  blood  in  the  part;  while  the  dilatation  which 
comes  with  the  reaction  to  a  cold  application  is  accompanied 
by  an  increase  in  blood  pressure,  the  tone  of  the  vessels  is  pre- 
served, and  there  is  a  preponderance  of  arterial  blood  in  the 
part.  These  conditions  are  respectively  known  as  venous  or 
Passive  hyperemia  and  arterial  or  active  hyperemia.  It  is  import- 
ant to  distinguish  the  physiologic  difference  between  the  hyper- 
emia of  cold  and  that  of  hot  applications.  At  first  both  pro- 
duce an  arterial  hyperemia.  In  the  case  of  the  hot  application 
the  end  result  is  a  slowing  of  the  circulation,  a  stasis  of  blood, 
which  necessarily  results  in  an  increase  of  the  venous  over  the 
arterial  blood  in  the  part.  With  the  cold  application,  after  the 


96 


BLOOD  PRESSURE 


initial  vasoconstriction  and  anemia  have  given  way,  the  return 
to  a  normal  condition  (reaction)  is  accompanied  by  an  increase 
of  from  three  to  five  times  in  the  rapidity  of  the  circulation.10 
The  blood  flows  rapidly  through  the  part  and  consequently, 
arterial  blood  predominates.  The  remote  result  is  the  same; 
there  is  no  after- tendency  to  stasis.  This  is  no  small  factor  in 
nutrition  and  healing.  In  fact,  it  is  upon  the  blood  that  they 
depend;  they  are  carried  on  and  hastened  in  proportion  to  the 
amount  of  arterial  blood,  i.  e.,  nutrition  and  oxygen,  supplied 
to  the  tissues. 


Fig.  25.    Faught's  sphygmomanorrieter. 

Bier,  in  his  work  on  the  treatment  of  disease  by  hyperemia, 
claims  for  the  tissues  a  selective  action,  i.  e.,  that  they  have  the 
power  to  select  arterial  in  preference  to  venous  blood.  It  would 
appear  irrational  to  suppose  anything-  else.  The  essential  fea- 
ture is  not  in  the  selective  action,  but  in  the  supplying  of  suffi- 
cient arterial  blood,  so  that  the  tissues  may  manifest  their 
selective  action.  The  cold  has  also  a  direct  action  on  the  hemo- 
globin in  producing  a  higher  degree  of  oxyg-enation,  /.  e.,  a 

10    Baruch— Principles  and  Practice  of  Hydrotherapy,  p.  55. 


MUELLER'S  LA  WS 


97 


greater  oxygen-carrying-  capacity  and  upon  the  tissues,  making 
it  possible  for  them  to  appropriate  more  oxygen.11 

The  pumping  action  of  the  arteries  under  the  influence  of 
reaction  to  cold  drives  the  blood  into  the  veins.  Because  of 
this,  the  right  side  of  the  heart  is  more  completely  filled,  and 
there  results  a  fuller  output  to  the  lungs  and  from  the  left  side 
of  the  heart.  These  forces  tend  to  produce  a  slower  and  more 
vigorous  systole,  and  so  the  entire  cycle  of  changes  brings 


Fig.  26.    Riva-Rocci  Sphygmomanometer. 

about  a  heightened  blood  pressure.     These  facts  demonstrate 
the  great  value  of  the  cold  mitten  friction  in  surgical  shock. 

Mueller's  Laws.     In  1902  Miiller,  in  experimenting  with  baths 
of  different  temperatures,  arrived  at  definite  conclusions  regard  - 


11  This  active  arterial  hyperemia  is  undoubtedly  due  to  the  action  of  cold  on  the 
tissues,  hemoglobin,  and  the  blood-vessels  themselves.  This  has  been  confirmed  by 
Ritter,  who  performed  two  very  interesting  experiments  to  demonstrate  this  fact.  By 
means  of  an  ethyl  chloride  spray  he  froze  a  spot  on  the  arm.  After  it  had  thawed  it 
became  bright  red  from  the  reaction.  He  then  applied  an  elastic  bandage  to  the  arm 
above  the  spot.  The  whole  arm  became  dark  blue,  while  the  previously  frozen  spot 
remained  bright  red.  He  reversed  the  experiment  by  first  producing  cyanosis  and 
venous  stasis,  and  then  freezing  a  spot  on  the  arm  below  the  bandage.  After  thawing,  it 
became  bright  red,  while  the  rest  of  the  arm  remained  blue. 


98 


BLOOD  PRESSURE 


ing:  the  effects  of  thermic  applications  upon  blood  pressure. '- 
The  pressure  was  tested  by  means  of  the  Riva-Rocci  sphygrno- 
manometer  (Fig.  26.).  Briefly  stated  his  conclusions  are  as 
follows  (Plate  1 ']/.):— 

1.  Effects  of  Cold.     Baths  and  thermic  appli- 
cations, not  accompanied  by  mechanical  irrita- 
tion, if  given  below  the  temperature  of  the  skin, 
produce  increased  blood  pressure  with  slowed 
pulse  rate. 

2.  Effects  of  Heat.      Thermic    applications 
above  the  skin  temperature,    after   a   brief  rise, 
produce  a  fall  in   blood    pressure   which    later 
rises.     Hot  baths  above  104°  F.  persistently  in- 
crease blood  pressure  and  the  pulse  rate. 

3.  Effects  of  Neutral  Tem- 
peratures.     Neutral     baths 
equalize    or    regulate    blood 
pressure. 

4.  Effects    of    Mechanical 
Stimuli.     With   douches  and 
other  procedures,  where  the 
mechanical  irritation    is    the 
predominant 

factor,  there  is 
a  rise  of  blood 
pressure  less  en- 
during  than 
with  cold  appli- 
cations. "Every 
hot  or  cold 

douche  calls  forth  an  increase  of  blood  pressure,  paradoxical 
as  it  may  seem." 

The  experiments  of  Schuller,  already  quoted,  sustain  these 

observations.     Many  other  experiments  along-  this  line  mfeht 

J    quoted.     Kellogg:"   records    an   experiment    in  which    the 

?_of  a  large  quantity  of  cold  fluid  (50°  F.)  raised  the 

!    Mflller-Deutsch.  Arch,  flir  klin.  Med..  1902.  Vol  74 

Hinsdale—  Hydrotherapy,  p.  48. 
14    Rational  Hydrotherapy,  p.  1115. 


Fig.  27.    Gartner's  Tonometer. 


Minutes 
10      20      30      40       50      60     70       80 

Hg. 

140 

A 

130 

ft 

\ 

120 

/ 

A 

\ 

110 

7 

\\ 
• 

^ 

\ 

\ 

• 

^N 

Js 

^ 

i 

•v,^. 

Water  Bath  at  42.5°C. 

120 
110 

lAfl 

\ 

A^ 

-v 

\^>  • 

££ 

*~~ 

••—  -• 

V 

»-^ 

^ 

^ 

r^ 

Water  Bath  at  36.25°C. 

•  on 

120 
110 

inn 

A. 

_A^ 

Hi 

V  ' 

v 

* 

-^ 

•**«- 



****• 

^ 

en 

/ 

'^ 

^ 

H 

~-J 

T 

Water  Bath  at  28.75°  C. 

PLATE  IV.  Chart  showing  influence  of  baths  of  different  tem- 
peratures on  blood  pressure  and  pulse  rate  in  a  healthy  man  of 
twenty-six;  red  lines— blood  pressure,  black  lines — pulse  rate. 
(Riva-Rocci's  sphygmj  (Muller.) 


BLOOD  PRESSURE  EFFECTS  99 

capillary  arterial  tension,  as  taken  by  Gartner's  tonometer 
(Fig.  27.}  from  13.5  cm.  to  14.5  cm.  The  first  observation 
was  made  immediately  before,  and  the  second  immediately  after 
the  drinking-  of  the  cold  water.  In  another  clinical  experi- 
ment '°  an  initial  arterial  tension  of  9  cm.  was,  by  an  electric 
light  bath,  raised  to  10  cm.  within  one  minute.  At  the  end  of 
five  minutes  the  tension  had  fallen  to  8  cm.  and  in  twenty  min- 
utes to  7  cm.  In  another  case  16  fifteen  minutes  in  a  full  bath 
at  102°  F.  reduced  the  blood  tension  from  9  cm.  to  6  cm.  as 
shown  by  Gartner's  tonometer. 

Hot  air  baths  decrease  blood  pressure  as  shown  in  a  series  of 
observations  by  Tuttle 17  the  average  decrease  in  twenty  cases 
was  12  mm.  of  mercury.  Cold  douches  following  this,  quickly 
raised  the  blood  pressure  to  normal,  slightly  below  or  slightly 
above. 

Carbonated  baths  have  a  tendency  to  raise  blood  pressure, 
although  J.  M.  Swan18  has  shown  that  this  effect  is  not  con- 
stant. The  marked  results  of  the  artificial  Nauheim  bath  are 
probably  due  more  to  the  stimulation  of  vascular  activity,  i.  e., 
of  the  peripheral  heart  than  to  vasoconstriction.  The  same 
may  be  said  of  the  oxygen  bath,  though  the  majority  of 
observers  agree  that  its  most  usual  result  is  a  lowering  of 
blood  pressure. 

The  breathing  of  cold  air  raises  the  blood  pressure.  B.  R. 
Hoobler 19  observed  a  gradual  increase  of  the  low  pressure  in 
children  suffering  from  tuberculosis,  when  these  children  were 
transferred  to  the  open  air.  The  raised  pressure  became  more 
and  more  permanent  as  the  out-door  treatment  was  continued. 
These  matters  are  discussed  further  in  the  part  on  therapeutics 
in  connection  with  the  treatment  of  various  diseases. 


15  Kellogg— Rational  Hydrotherapy,  p.  1122. 

16  Ibid.  p.  1128. 

17  American  Journal  of  Insanity,  October,  1904. 

18  Archives  of  Internal  Medicine,  August  15,  1912,  p.  73. 

19  American  Journal  of  Diseases  of  Children,  November  20,  1912. 


CHAPTER  X 

THE  CIRCULATION-CHANGES  IN  THE 
COMPOSITION  OF  THE  BLOOD 

CORPUSCULAR  ELEMENTS 

SUCH  a  large  volume  of  experimental  work  has  been  re- 
ported along  this  line  that  we  can  not  do  more  than  tabu- 
late the  principal  results  observed.  The  investigations  of 
Professor  Winternitz,  and  those  of  Strasser,  undertaken  at  his 
request  and  reported  in  1893,  are  considered  the  basis  of  our 
knowledge  of  these  changes.  The  results  obtained  by  all 
observers  are  so  uniform  as  to  leave  no  doubt  of  their  reliability. 
After  all  sorts  of  cold  procedures,  involving  the  general  skin 
surface  and  associated  with  mechanical  procedures,  after  hot 
baths  or  douches  when  followed  by  cold  applications,  the  blood 
counts  reveal  an  increase  in  both  the  red  cells  and  white  cells, 
and  a  marked  change  in  their  ratio.  In  Winternitz'  experi- 
ments the  greatest  increase  in  red  cells  amounted  to  1,860,000 
per  cubic  millimeter;  in  white  cells,  from  200  to  300  per  cent; 
and  in  hemoglobin,  14  percent. 

On  the  first  and  third  bath  days  of  Strasser' s  experiments, 
referred  to  in  Chapter  XI,  blood  counts  were  taken  after  the 
cold  douche  and  after  the  graduated  half  bath.  The  counts 
were  as  follows: — 

Effects  of  Cold  Douche  Before  After 

Red  cells  4,570,000         5,200,000 

White  cells  4,600  6,400 

Hemoglobin  (Fleischn  85%  95% 

(100) 


BLOOD  COUNT 
Effects  of  Graduated  Half  Bath       Before 

Red  cells  4,880,000 

White  cells  5,400 

Hemoglobin  -  85% 

The  results  in  detail  of  some  of  the  experiments  performed 
by  Winternitz  are  given  in  the  accompanying-  chart  (.Fig.  28.} 
and  table.1 


After 

5,420,000 
8,400 
95% 


Reds. 


$5%  20OOO 

815%  24000 
82£%  22000 
77.5%  ZOOOO 
100%  IBOOO 
65.0%  11000 
57.5%  ISOOO 
52.5%I3000 
QS.9%  11000 
tO.0%  9000 
35.0%  7000 
17.5%  5000 
22.52  4000 
11.5%  ZOOO 


I.OOOQOO 
sooooo 


Fig.  28.  Chart  showing  the  effects  of  hydriatic  procedures  on  the 
blood  count  and  hemoglobin.  Upright  blocks  with  diagonal  lines- 
red  count,  blocks  with  horizontal  cross  lines — white  count,  blocks  in 
black— hemoglobin  per  cent.  (Winternitz.) 


Cold  Full  Bath 
Before 

Immediately  after 
After  plus  1-2-hr,  rest  in  bed 

Cold  Rain  Bath 

Before 

After  plus  1-2-hr,  exercise 

Scotch  Douche 
Before 
After  plus  1-hr,  exercise 


Red  Cells         White  Cells       Hgb 


5,380,000 
5,222,000 
5,422,000 

4,820,000 
5,510,000 

4,460,000 
5,000,000 


8,400 
16,700 
21,640 

4,500 
10,600 


7,400 
11,600 


70% 


87% 
95% 

74% 

77% 


1     B.  Buxbaum — Lehrbuch  der  Hydrotherapie,  II  Auflage,  p.  35. 


102  BLOOD  COMPOSITION 

These  changes  were  maintained  for  from  one-half  hour  or  one 
hour  up  to  two  hours  or  longer  after  applications,  gradually 
returning  to  normal.  The  increase  in  the  white  cells  was 
maintained  longer  than  the  increase  in  reds.  These  observa- 
tions have  been  confirmed  by  Thayer,  Baruch,  and  Kellogg,  in 
this  country. 

Where  do  these  cells  come  from?  Repeated  cold  applications 
stimulate  hematogenesis,  as  they  stimulate  all  other  functions, 
as  is  shown  by  the  fact  that  in  cases  of  anemia  this  increase  in 
cells  continues  longer  and  longer  after  each  succeeding  appli- 
cation until  finally  a  normal  count  is  reached  and  maintained. 
But,  of  course,  so  great  an  increase  as  30  or  35  per  cent  in  the 
total  number  of  reds  and  200  per  cent  in  the  total  number  of 
whites  could  not  result  from  a  single  application.  This  increase 
in  the  corpuscular  elements  in  the  peripheral  circulation  must 
be  at  the  expense  of  the  number  elsewhere.  Winternitz  claims 
that  this  increase  of  cells  in  the  peripheral  circulation  is  due  to 
the  driving  of  large  numbers  of  cells  from  the  viscera,  where 
stasis  has  taken  place.  Breitenstein 2  has  confirmed  this  view  by 
experiments  upon  rabbits.  These  animals  were  overheated  in 
a  hot  box,  before  and  after  which  the  red  cells  in  the  peripheral 
circulation  (ear)  and  viscera  (liver)  were  estimated.  Before 
the  heating  process,  the  cells  in  the  ear  and  liver  were  equal 
in  number.  After  it,  there  was  an  enormous  increase  in  the 
red  blood  cells  in  the  liver.  Tschlenoff  observed  a  decrease  of 
50  per  cent  in  the  white  cells  in  rabbits  subjected  to  a  temper- 
ature of  42°  C.  for  five  or  six  hours.  These  experiments  also 
confirm  the  observation  of  Winternitz  and  others,  that  general 
hot  applications,  much  prolonged,  decrease  the  blood  count  and 
the  hemoglobin  per  cent,  the  white  cells  suffering  a  greater 
diminution  than  the  reds. 

Not  the  least  interesting  of  the  observations  made  by  Winter- 
nitz is  that  relating  to  the  local  increase  in  the  blood  count 
taken  from  circumscribed  areas  treated  by  cold  or  hot  and  cold 
douches,  partial  baths,  etc.,  while  counts  taken  from  a  distant 
part  showed  a  decrease  in  both  the  red  and  white  cells.  Pro- 
longed local  applications  of  heat  not  followed  by  cold,  while 

2    Archiv.  fflr  Exper.  Path,  und  Pharm..  Bd.  32,  1896. 


MECHANISM  OF  DISTRIBUTION  103 

resulting-  in  a  local  decrease  of  red  cells  and  hemoglobin,  in 
most  cases  produced  an  increase  in  the  leucocytes  in  the  same 
part.3  This  experiment  furnishes  a  rational  basis  for  the  local 
use  of  thermic  applications  to  an  infected  part. 

Massage  as  well  as  hydrotherapy  produces  an  increase  in  the 
number  of  the  blood  corpuscles,  as  shown  by  counts  taken  before 
and  after  treatment.  The  effect  is  at  first  temporary,  but  lasts 
longer  and  longer  as  the  massage  is  continued  from  day  to  day 
or  week  to  week  until  finally  the  improvement  becomes  perma- 
nent. Astonishingly  good  results  have  been  reported  by 
Mitchell 4  in  cases  of  anemia. 

Mechanism  of  Distribution.  The  change  in  the  distribution 
of  the  red  and  white  cells  produced  by  cold  applications  is 
to  a  great  degree  due  to  the  stimulation  of  the  peripheral 
circulation.  This  is  not,  however,  the  only  factor  in  bring- 
ing about  an  increase  of  cells  in  the  surface  circulation. 
The  viscera  and  their  blood-vessels  are  subject  to  the  reflex 
stimulation  produced  by  cold  applications.  The  contraction 
of  the  viscera  and  the  visceral  blood-vessels,  caused  by  cold 
applications,  drives  their  contained  corpuscles  to  other  parts, 
and  these  are  taken  up  by  the  increased  activity  of  the  peri- 
pheral circulation  and  so  redistributed.  In  both  the  liver  and 
spleen  the  blood  cells  are  especially  prone  to  accumulation 
and  stasis.  The  blood-vessels  of  both  may  be  rendered  very 
active;  but  owing  to  the  additional  muscle  fibers  in  the  capsule 
and  trabeculae  of  the  spleen,  this  organ  exerts  a  greater  effect 
upon  the  blood  current  than  any  other  viscus  except  the  heart. 
'  The  most  definite  facts  known  about  the  spleen  are  in  con- 
nection with  its  movements.  It  has  been  shown  that  there  is  a 
slow  expansion  and  contraction  of  the  organ  synchronous  with 
the  digestion  periods.  After  a  meal  the  spleen  begins  to  in- 
crease in  size,  reaching  a  maximum  at  about  the  fifth  hour,  and 
then  slowly  returns  to  its  previous  size.  This  movement,  the 
meaning  of  which  is  not  known,  is  probably  due  to  a  slow 
vasodilatation,  together,  perhaps,  with  a  relaxation  of  the 
tonic  contraction  of  the  musculature  of  the  trabeculae.  In  ad- 
dition to  this  slow  movement,  Roy  has  shown  that  there  is  a 

3  Even  in  general  hot  applications  a  pronounced  leucocytosis  •was  often  observed. 

4  Journal  of  American  Medical  Association,  October  9,  1909,  p.  1183. 


104  BLOOD  COMPOSITION 

rhythmical  contraction  and  relaxation  of  the  organ,  occurring 
in  cats  and  dogs  at  intervals  of  about  one  minute. 

' '  Roy  supposes  that  these  contractions  are  effected  through 
the  intrinsic  musculature  of  the  organ, — that  is,  the  plain 
muscle  tissue  present  in  the  capsule  and  trabeculae, — and  he 
believes  that  the  contractions  serve  to  keep  up  a  circulation 
through  the  spleen  and  to  make  its  vascular  supply  more  or  less 
independent  of  variations  in  general  arterial  pressure.  The 
fact  that  there  is  a  special  local  arrangement  for  maintaining  its 
circulation,  makes  the  spleen  unique  among  the  organs  of  the 
body,  but  no  light  is  thrown  upon  the  nature  of  the  function 
fulfilled.  The  spleen  is  supplied  richly  with  motor  nerve  fibers 


Doc  8  5  KILO  ALL  CONNCCTIONS  WITH  SPLE.EN 

SEVERED   CXCE.PT  ONE  ARTERV  *   VEIN  * 
0  PRESSURE 


Fig.  29.  Plethysmographic  tracing  of  spleen  (upper  curve)  from  dog 
showing  the  spontaneous  rhythmical  contractions  of  this  organ. 
(Schafer  after  Starling.) 

which,  when  stimulated  either  directly  or  reflexly.  cause  the 
organ  to  diminish  in  volume.  According  to  Schafer  these 
fibers  are  contained  in  the  splanchnic  nerves,  which  carry  also 
inhibitory  fibers  whose  stimulation  causes  a  dilatation  of  the 
spleen." 

The  blood  of  the  splenic  veins  contains  a  much  greater  num- 
ber of  white  cells  than  the  arterial  blood  supplied  to  the  organ. 
Ifieacher*  experimenting  with  Rhine  salmon  found  four  times 
as  many  leucocytes  in  the  splenic  blood  as  in  the  cardiac  blood. 
This  increase  in  the  cellular  elements  increases  the  viscosity, 

5  Howell— Physiology,  1909.  p.  800. 

6  Bunge— Physiologic  and  Pathologic  Chemistry.  Second  English  Edition,  p.  229. 


VISCOSITY  105 

and  consequently  tends  to  diminish  the  rate  of  blood  flow.  The 
gathering  up  of  these  cells,  together  with  the  closeness  of  the 
splenic  meshwork  in  which  the  blood  circulates,  makes  neces- 
sary some  mechanism  for  additional  propulsive  force. 

"It  is  evident  that  the  blood  must  meet  with  considerable 
resistance  in  passing  through  the  close  meshwork  of  the  splenic 
pulp.  To  ensure  a  constant  circulation  through  the  gland,  we 
find  that  the  muscular  tissue  of  the  capsule  and  trabeculae 
has  the  property  of  rhythmic  contraction.  If  the  spleen  be 
inclosed  in  a  plethysmograph,  or  splenic  oncometer,  and  its 
volume  be  recorded  by  connecting  this  with  the  oncograph,  it 
will  be  seen  that  it  is  subject  to  a  series  of  large,  slow  varia- 
tions, each  contraction  and  expansion  lasting  about  a  minute, 
and  recurring  with  great  regularity  (Fig.  29.).  Superposed  on 
these  large  waves  are  seen  the  smaller  undulations  due  to  the 
respiratory  variations  of  the  blood  pressure,  and  on  these  again 
the  little  excursions  corresponding  to  each  heart  beat.  The 
contractile  power  of  the  spleen  is  under  the  control  of  the 
nervous  system,  and  a  rapid  contraction  may  be  induced  by 
stimulation  of  the  splanchnic  nerves."  7 

The  use  of  cold  applications,  especially  when  accompanied  by 
mechanical  stimulation,  such  as  the  cold  mitten  friction  to  the 
abdomen  and  the  cold  splenic  douche,  have  a  decidely  stimu- 
lant effect  upon  the  movements  of  the  spleen.  The  same  is 
true  of  the  revulsive  compress  and  the  alternate  hot  and  cold 
douche  to  the  splenic  region  and  abdomen.  Such  stimulation 
increases  the  extent  and  force  and  greatly  enhances  the  effi- 
ciency of  the  splenic  contractions,  thereby  proving  a  powerful 
means  of  accomplishing  the  even  distribution  of  the  blood  cells, 
especially  the  leucocytes. 

VISCOSITY 

Grawitz  and  also  Burton-Opitz 8  have  shown  that  cold  appli- 
cations increase  the  viscosity  and  specific  gravity  of  the  blood, 
while  warm  applications  decrease  both.  This  thinning  of  the 
blood  continued  even  after  prolonged  heating  with  free  perspi- 


7  Starling— Elements  of  Human  Physiology.  1907,  p.  514. 

8  Journal  of  Experimental  Medicine,  January,  1906. 


ALKALINITY  OF  THE  BLOOD 


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FIR.  30.  Chart  showing  changes  in  the  alkalinity  of  the  blood  under 
thermic  procedures.  Figures  at  left  refer  to  alkalinity  of  100  c.  c.  of 
blood  serum  in  terms  of  c.  c.  of  decinormalNaOH.  (Strasserand  Kuthy.) 


(106) 


ACIDITY  OF  THE  URINE 


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Fig.  31.  Chart  showing  changes  in  the  acidity  of  the  urine  un- 
der thermic  procedures.  Figures  at  the  left  refer  to  per  cent  of  de- 
crease in  acidity  under  cold  treatment;  figures  at  right,  to  per  cent  of 
increase  in  acidity  under  hot  treatment.  (Strasser  and  Kuthy.) 

(107) 


108  BLOOD  COMPOSITION 

ration.  This  result  Burton-Opitz  attributed  to  the  blood  be- 
coming relatively  richer  in  serum  at  the  expense  of  the 
tissues.  These  facts  have  been  confirmed  by  Lowy  and  agree 
with  the  deductions  of  Winternitz  and  Knopf elmacher. 

In  general,  it  may  be  said  that  conditions  that  produce  vaso- 
constriction,  increase  the  number  of  corpuscles  in  the  vessels 
constricted,  together  with  an  increase  in  the  specific  gravity 
and  viscosity  of  the  blood.  Conversely,  conditions  that  relax 
the  blood-vessels,  decrease  the  corpuscular  elements  in  the 
dilated  vessels,  together  with  a  thinning  of  the  blood. 

REACTION 

Strasser  and  Kuthy 9  performed  experiments  to  determine  the 
effect  of  hydriatic  procedures  upon  the  chemical  reaction  of  the 
blood  and  urine.  They  found  that  procedures  raising  the  body 
temperature,  /.  e.,  much  prolonged  heating  measures,  result  in 
lessening  the  degree  of  alkalescence  of  the  blood:  also  that  cold 
stimulating  procedures  increase  the  alkalescence  (Fig.  30.}. 
Strasser  concludes  that  the  result  in  the  case  of  cold  baths  is 
due  to  an  increase  of  oxidation  over  disintegration,  i.e.,  to 
completer  burning  of  acid  organic  substances,  and  hence  to  their 
disappearance.  This  is  precisely  what  happens  to  the  organic 
acids  and  acid  organic  salts  of  fruits  and  green  vegetables. 
The  organic  radicle  undergoing  oxidation,  largely  into  CC>2  and 
thO,  leaves  in  the  blood  and  body  fluids  the  alkaline  base  of  the 
salt  and,  therefore,  raises  the  alkalinity  of  these  fluids.  While 
heating  procedures  increase  oxidation,  they  bring  about  a 
greater  disintegration  of  tissue,  i.  e.,  partial  combustion  and  so 
result  in  an  acidification,  which  acid  products  remain  to  be 
excreted  as  such  in  the  urine. 

That  Strasser 's  deductions  are  correct  is  shown  by  the 
changes  in  the  acidity  of  the  urine  accompanying  these  changes 
in  the  alkalinity  of  the  blood.  (Fig.  31.}  In  the  case  of  cold 
procedures  there  occurs  a  decrease  in  the  acidity  of  the  urine 
parallel  with  the  decrease  in  the  acid  of  the  blood  (increase  of 
alkalescence),  thus  proving  that  the  acidifying  substances  have, 
to  that  extent,  wholly  disappeared.  Conversely,  in  the  heating 

9  Deutsche  Medizinal-Zeitung.  June  15,  18%.  quoted  from  B.  Buxbaum— Lehrbuch  der 
Hydrotherapie.  II  Auflage.  pp.  38.  39. 


PRACTICAL  APPLICATION  109 

procedures  an  increase  of  acid  in  the  blood  (decrease  of  alkal- 
escence) is  accompanied  by  a  like  increase  in  the  acidity  of  the 
urine,  showing-  an  actual  increase  in  acidifying-  substances  unoxi- 
dized,  and  hence  coming  to  excretion  as  such. 

PRACTICAL  APPLICATION 

Some  of  the  most  beneficial  results  of  hydriatic  measures  are 
due  to  the  facts  recorded  above.  In  the  majority  of  diseases, 
there  is  a  reduction  in  the  alkalinity  of  the  blood.  This  is  par- 
ticularly true  of  fevers  and  infectious  diseases.  An  agent  which 
will  tend  to  restore  the  blood  to  its  normal  alkalinity  will  hasten 
all  the  processes  of  repair  and  raise  vital  resistance  by  supply- 
ing a  more  normal  medium  for  the  phagocytes. 

The  role  of  the  leucocyte  (phagocytosis )  in  combating  infec- 
tion is  now  an  established  fact.  The  admirable  researches  of 
Metchnikoff  along  this  line  leave  no  doubt  that  the  white  cell 
itself  is  the  prime  factor  (and  that  not  excepting  opsonin)  in 
phagocytosis,  the  production  and  maintenance  of  immunity  and 
the  body's  general  resistance  to  bacterial  invasion.  He  has 
shown 10  what  signal  disaster  to  the  production,  and  even  the 
continuance  of  immunity,  results  from  the  administration  of 
alcohol,  quinine,  -opium,  and  other  medicinal  substances;  this 
disaster  being  manifest  by  a  diminution  in  the  number  and 
especially  in  the  activity  of  the  white  blood  cells.  He  further 
recommends  the  discarding  of  medicinal  substances  and  the  use 
of  hygienic  measures  in  the  prophylaxis  and  treatment  of  infec- 
tious diseases.  We  have  every  reason  to  believe  that  cold 
hydriatic  applications  not  only  increase  the  number  of  leuco- 
cytes in  the  peripheral  circulation,  but  also  energize  their 
action — amoeboid  movements,  phagocytosis,  and  the  production 
of  antibodies.  This  we  might  safely  infer  from  the  results 
obtained  by  cold  applications  in  increasing  muscular  capacity, 
glandular  activity,  etc.  All  protoplasm,  whether  of  muscle 
cells,  glandular  epithelium,  or  leucocyte,  responds  alike  to  the 
tonic  influence  of  short  vigorous  cold  applications.  The  writer 
has  repeatedly  seen  infections  of  the  hand  and  arm  clear  up  in 
four  to  six  days,  or  even  less  time,  when  treated  by  alternating 

10    The  New  Hygiene. 


110  BLOOD  COMPOSITION 

extreme  hot  and  cold  immersion,  while  other  cases  not  so 
treated  have  required  a  month  to  accomplish  the  same  results. 

Since  the  blood  and  tissue  cells  are  the  source  of  opsonin, 
agglutinins,  lysins,  and  other  antibodies  concerned  in  immunity, 
it  is  but  reasonable  to  expect  an  increase  in  these  as  a  result  of 
the  cellular  stimulation  produced  by  cold  or  alternate  hot  and 
cold  applications.  This  has  been  partially  demonstrated  by 
Graziani,11  who  found  that  of  rabbits  injected  with  the  filtrates  of 
typhoid  cultures,  and  kept  at  different  temperatures  (plus  38, 
37,  2,  and  minus  4°  C.),  those  kept  at  low  temperatures  devel- 
oped more  agglutinin  than  those  kept  at  higfher  temperatures. 
He  also  experimented  with  rabbits  kept  at  32°  C.,  bathing-  half 
of  the  number  morning-  and  evening,  in  water  at  20°  C.  for 
thirty  minutes.  The  animals  treated  by  bathing  produced  more 
agglutinin  than  the  others. 

These  facts  demonstrate  the  truth  of  the  Scripture  statement 
that  the  blood  is  the  life.  The  statement  has  not  only  its  spirit- 
ual application,  but  is  also  founded  upon  demonstrated  physical 
facts. 

"Notwithstanding  the  many  antiseptics,  germicides,  etc.,  that 
have  been  vaunted  for  the  treatment  of  infectious  diseases,  the  ivhite 
blood  cell  itself  is  the  most  efficient  germicide  known,  and  will 
always  retain  its  high  place  in  the  defence  of  the  body  against  bac- 
terial invasion;  furthermore,  the  agent  which  assists  the  body  by 
augmenting  its  natural  powers  of  defence  will  never  occupy  a  place 
secondary  to  purely  artificial  and  chemical  means  of  destroying  the 
invaders." 

11  Centralblatt  filr  Bakteriologie,  1907.  I,  XLII,  633. 

12  Abbott— Elements  of  Hydrotherapy  for  Nurses,  p.  54. 


CHAPTER  XI 

NITROGENOUS  METABOLISM  AND 
EXCRETION 

TISSUE  changes  lie  at  the  foundation  of  all  functional  activ- 
ity. There  can  be  no  vital  action  without  corresponding 
qualitative  and  quantitative  changes  in  tissue  composition.  It 
must,  therefore,  follow  that  agents,  such  as  thermic  impressions, 
in  awakening  functional  activity,  should  at  the  same  time  pro- 
duce profound  alterations  in  absorption,  metabolism  and  excre- 
tion. Without  giving  undue  prominence  to  this  phase  of  the 
subject,  it  would  be  impossible  to  discuss  it  here  in  anything 
like  a  complete  manner.  Those  desiring  to  become  more 
thoroughly  conversant  with  the  behavior  of  metabolism  under 
hydriatic  therapy  should  study  the  original  reports  of  such  re- 
search. Along  the  line  of  nitrogenous  metabolism  none  are 
more  instructive  than  those  of  Dr.  Alois  Strasser,  assistant  to 
Prof.  W.  Winternitz  in  the  Allegemeine  Poliklinik  of  Vienna, 
from  whose  monograph  entitled,  '"The  Behavior  of  Metabol- 
ism under  Hydriatic  Therapy,"  l  is  drawn  much  of  the  data  for 
the  following  discussion. 

Cellular  activity  is  affected  reflexly  in  the  same  way  as  other 
body  functions.  Tissue  changes  occur  in  all  parts  of  the  body, 
but  those  metabolic  activities  with  which  we  are  chiefly  con- 
cerned may  be  traced  to  the  muscles  as  the  seat  of  the  great 
majority  of  oxidative  processes.  The  liver  is  also  to  a  large 
extent  concerned  in  metabolism,  both  nitrogenous  and  carbon- 
aceous. It  is  not  necessary  that  the  muscles  be  excited  to 


1  Das  Verhalten  des  Stoffwechsels  bei  hydratischer  Therapie— Fortschritte  der  Hydro- 
therapie,  Festschrift  zum  Vierzigjahrigen  Doctor jubilaum  des  Prof.  Dr.  W.  Winternitz, 
herausgegeben  von  Dr.  A.  Strasser  und  Dr.  B.  Buxbaum,  Wein,  1897. 

(Ill) 


112  NITROGENOUS  METABOLISM 

perceptible  contraction  in  order  to  effect  metabolic  changes. 
Through  the  innervation  of  the  muscles,  oxidation  is  controlled 
and  may  be  gfreatly  increased  by  hot  or  cold  applications,  with- 
out visible  contractions.  This  conclusion  was  arrived  at  by 
Rohrig  and  Zuntz  who  further  confirmed  their  opinion  by  ex- 
periments upon  animals  "in  which  the  innervation  of  the 
muscles  was  held  in  obeyance  by  arrow  poison.  In  such  ani- 
mals tissue  change  was  not  only  not  increased  by  cold,  but  was 
even  reduced  one-half."  Other  stimuli  than  cold  also  affect 
tissue  changes.  The  relative  value  of  various  cutaneous  stimuli, 
varying  degrees  of  heat,  and  the  quantitative  response  of  meta- 
bolism is  best  studied  with  carbonaceous  metabolism  (g.  v.). 

EFFECTS  OF  COLD 

Strasser  conducted  two  series  of  experiments  at  different 
times.  In  \hefirst  series  two  young  men  were  selected  as  sub- 
jects. The  daily  ration,  urine,  and  feces  were  carefully  meas- 
ured, and  from  chemical  analyses  and  estimations  from  these, 
the  results  were  obtained.  The  procedures  were  such  as  would 
ordinarily  be  administered  to  patients.  In  the  second  series  a 
single  individual  was  chosen.  In  this  series  the  intake  con- 
tained 122  gm.  of  proteid  (19.0  gm.  nitrogen)  besides  carbohy- 
drate and  fat.  The  output  in  feces  and  urine  was  measured  for 
five  days  in  order  to  establish  the  normal  quantities  of  the 
various  constituents  for  the  individual  under  experiment. 
'  The  bath  period  lasted  three  days.  On  each  day  the  man 
received  in  the  morning  at  8 'o'clock  a  friction  at  14°  R.  (63.5° 
F.).  Forenoons  at  11:30  a  general  cold  ram  bath  with  moving 
fan  douche,  and  afternoons  a  half  bath  at  22°  cooled  to  18°  R. 
(81.5°  to  72.5°  F.)  of  four  minutes  duration.  Moderate  exer- 
cise followed  each  procedure,  as  much  as  seemed  necessary  for 
warming,  i.  <?.,  the  attainment  of  a  good  reaction." 

.  The  results  of  the  first  work  as  tabulated  by  Strasser  are  as 
follows: — 

1.  Increase  of  nitrogen  metabolism,  i.  e.,  increase  of  the 
nitrogen  excretion  in  the  urine;  a  simultaneous  decrease  in 
fecal  nitrogen. 

2    Baruch— Hydrotherapy.  p.  80. 


NITROGEN  ECONOMY 


113 


2.  Absolute  and  relative  increase  in  the  excretion  of  urea. 

3.  Higfh  absolute  increase  in  the  excretion  of  uric  acid,  with 
relative  proportion  almost  unchanged. 

4.  Higfh  absolute  and  relative  increase  in  phosphorus  excre- 
tion. 

5.  Small  relative  fluctuations  in  ammonia  excretion. 

6.  Decrease  in  the  sum  of  the  extractives  to  a  minimum. 

The  results  in  the  second  series  of  experiments  entirely  con- 
firmed the  findings  in  the  first,  and  are  of  the  same  general 
character.8 


Prejteriod     |  BqlhpeTiool  Afterjteriod 
Urinary -N 


Fecal-N 


Fig.  32.    Showing-  the  effect  of  cold  treatment  on  fecal  and  urinary 
nitrogen— reveals  a  heightened  assimilation  of  proteid.     (Strasser.) 

Nitrogen  Economy.  The  excretion  of  nitrogen  (.Fig.  32.)  on 
the  first  bath  dav  was  increased  8.3  per  cent  over  the  average 
of  the  preperiod;  a  maximum  increase  of  11.4  per  cent  was 
reached  on  the  second  day,  and  on  the  last  6.0  per  cent,  thus 
averaging  8.6  per  cent.  The  increase  continued  throughout  the 
after-period.  In  the  two  first  cases  the  average  increase  was 
respectively  10  and  16.4  per  cent.  The  fecal  nitrogen  shows 
a  corresponding  decrease.  The  subject  of  the  experiment  re- 
mained practically  in  nitrogen  balance  throughout  the  experi- 

3.    Unless  otherwise  stated  the  charts  and  estimations  refer  to  the  second  series  of  ex- 
periments. 


Fig-.  33.    Showing  relative  increase  of  urea  and  the  phosphates 
and  relative  decrease  of  ammonia.    (Strasser.) 


(114) 


UREA  AND  AMMONIA  115 

ment.     The  decrease  in  fecal  nitrogen  is  to  be  explained  by  an 
increased  absorption  of  proteid. 

The  tonic  influence  of  the  reaction  to  cold  procedures  brings 
about  an  increased  digestive  efficiency,  hastens  the  processes  of 
absorption  and  assimilation  and  renders  them  more  complete. 
Clinical  observations  have  also  established  the  fact  that  hydriatic 
treatment  properly  suited  to  the  patient's  reactive  ability  decid- 
edly and  enduringly  enhances  assimilation. ' 

Urea  and  Ammonia.  In  Strasser's  experiments  there  was 
an  absolute  increase  of  urea  in  all  cases.  In  the  second  series 
this  increase  averaged  12  per  cent  during  the  bath  period  and 
6.5  per  cent  during  the  after-period.  In  the  first  series  the 
greatest  increase  in  the  two  cases  was,  respectively,  18  and  25 
per  cent  and  the  averages  10  and  21.1  per  cent.  Relative  to 
the  total  nitrogen,  there  was  also  an  increase  as  graphically 
shown,  in  Fig.  33.  From  an  average  proportion  of  86.9  per 
cent  of  the  total  nitrogen  in  the  preperiod,  the  nitrogen  content 
of  urea  rose  to  a  maximum  height  on  the  third  bath  day  of  92.5 
per  cent  of  the  total  nitrogen.  .  . 

Ammonia  being  a  precursor  of  urea,  and  both  being  derived 
from  proteid,  it  might  be  expected  that  its  amount  would  bear 
some  definite  relation  to  the  amount  of  urea  excreted.  In  the 
first  cases  there  was  both  an  absolute  and  a  relative  increase  in 
the  excretion  of  ammonia.  The  absolute  increase  in  one  case 
reaching  as  high  as  52.5  per  cent  and  averaging  42  per  cent  in 
one  and  36  per  cent  in  the  other.  In  the  after-period  one  sank 
to  33  per  cent  below  the  level  of  the  preperiod,  and  in  -the  other 
it  remained  30  per  cent  higher  than  in  the  preperiod.  In  the 
second  series  it  sank  to  normal  in  the  after-period.  Relative  to 
the  total  nitrogen,  the  increase  was  less  than  might  be  expected 
and  in  the  second  series  there  was  even  a  slight  relative  de- 
crease. Strasser  concludes  that  organic  acids  ordinarily  derived 
from  proteid  by  incomplete  oxidative  processes  (decomposi- 
tion) and  which  so  powerfully  contribute  to  lessening  the  alka- 
linity of  the  blood,  have,  under  the  influence  of  the  thermic 
stimulus,  been  burned  up  into  carbon  dioxide  and  water.  This 
decreased  amount  of  organic  acids  would,  he  reasons,  require 


116  NITROGENOUS  METABOLISM 

less  alkali  (ammonia)  for  their  neutralization  and  so  lessen  the 
relative  amount  of  the  latter  formed.4 

Uric  Acid  and  Purin  Bases.  The  accepted  theories  of  nuclei n 
metabolism  are  perhaps  too  well  known  to  need  explanation  here. 
An  increase  in  purin  excretion  may  arise  from  either  endogen- 
ous or  exogenous  purins.  That  the  increased  excretion  of  uric 
acid  is  due  to  heightened  activity  and  breaking  up  of  the  leuco- 
cytes and,  therefore,  bears  a  definite  relation  to  the  leucocytosis 
which  always  accompanies  the  reaction  to  cold  procedures,  can 
be  correct  in  part  only.  The  excreted  purins  must  of  neces- 
sity come  from  all  the  nuclear  nitrogen  of  the  body  as  well  as 
from  the  leucocytes.  The  more  complete  oxidation  of  exogen- 
ous purins  and  the  hastening  of  their  excretion  may  also  ac- 
count for  the  increase  in  uric  acid. 

The  results  obtained  by  different  experimenters  all  agree  as  to 
the  absolute  increase  in  uric  acid  excretion  under  the  influence 
of  thermic  procedures.  It  runs  parallel  with  the  excretion  of 
urea.  In  Strasser's  experiments  there  was  an  immediate  in- 
crease of  uric  acid  on  the  first  bath  day,  which  reached  a  maxi- 
mum of  25  per  cent  on  the  third  bath  day  and  an  average  of 
22  per  cent  during  the  entire  bath  period.  The  increase, 
though  somewhat  less  in  per  cent,  continued  throughout  the 
entire  after-period  at  an  average  height  of  12.7  per  cent  above 
the  level  of  the  preperiod.  The  results  in  the  two  cases  of  his 
first  series  entirely  coincided  with  this.  In  these  cases  the 
increase  in  the  total  purin  averaged  10.4  per  cent  during  the 
bath  period  and  even  a  higher  stage  was  reached  and  main- 
tained during  the  entire  three-day  after-period. 

Relative  to  the  total  nitrogen,  there  was  also  a  slight  increase. 
Of  100  parts  of  total  nitrogen  the  nitrogen  of  the  uric  acid  con- 
stituted 1.52  per  cent  in  the  preperiod,  1.71  per  cent  in  the 
bath  period  and  1.68  per  cent  in  the  after-period. 

4  It  would  seem,  however,  that  the  small  relative  increase  of  ammonia  is  due  to  the 
relatively  more  complete  conversion  of  ammonium  carbonate  into  urea,  its  end  product. 
As  a  product  of  proteid  metabolism  it  is  subject  to  increased  oxidation  in  common  with 
other  nitrogen  derivatives,  a  larger  relative  increase  is  prevented  by  the  increased  vigor 
of  hepatic  activity  tending  to  push  the  change  beyond  ammonium  carbonate  to  the 
formation  of  urea. 

Inorganic  acids  require  alkali  for  their  neutralization  as  well  as  organic  acids  and  the 
former  are  not  only  not  decreased  in  amount,  but  are  actually  increased.  For  further 
discussion  of  the  requirement  of  organic  acids  for  ammonia  and  fixed  alkali  see  Graham 
Lusk— Metabolism  in  Diabetes— Journal  American  Medical  Association.  December  17. 1910. 


PURIN 


117 


Of  particular  interest  in  connection  with  nuclein  metabolism 
is  the  behavior  of  the  purin  bases.  As  the  uric  acid  excretion  in- 
creases in  amount  the  purin  bases  progressively  decrease,  until 
on  the  third  bath  day  the  entire  purin  excretion  consists  of  uric 
acid,  the  bases  having-  wholly  disappeared.  At  the  close  of  the 
treatment  the  purin  bases  again  rise,  to  reach  on  the  third  day 


100%  =  N  of  all  Purin  Bodies 


Fig.  34.    Showing  effect  of  cold  treatment  on  the  oxidation  of 
purins.     (Strasser.) 

of  the  after-period,  the  height  of  the  preperiod.  This  change  in 
the  proportion  of  the  two  constituents  of  purin  excretion  is 
graphically  shown  in  Fig:.  34.  Letting  100  per  cent  represent 
the  total  purin  nitrogen,  85.5  per  cent  appears  as  uric  acid  and 
14.5  per  cent  as  purin  bases.  On  the  bath  days  the  per  cent  of 
uric  acid  rises  to  96,  then  to  98  and  finally  to  100  per  cent. 
The  nitrogen  content  of  the  bases  sinks  to  4,  then  to  2  and 
finally  to  0  per  cent. 


118  NITROGENOUS  METABOLISM 

With  the  composition  of  uric  acid  and  the  bases  in  mind,  the 
explanation  of  the  above  changes  is  not  difficult.  Uric  acid  is 
trioxypurin,  while  the  bases  all  contain  less  oxygen,  being 
mostly  mono-  or  dioxypurin,  with  amine  or  hydrocarbon  side 
groups.  Uric  acid  is,  therefore,  the  most  highly  oxidized  of  the 
purin  bodies.  It  is  plain  to  be  seen  that  the  stimulus  of  the 
hydriatic  procedures  has  resulted  in  oxidation  of  the  bases  to 
uric  acid,  a  distinct  cumulative  effect  being  manifest  by  the 
progressive  completeness  of  this  oxidation,  until  on  the  third 
bath  day  no  bases  are  left,  all  purin  nitrogen  appearing  as 
uric  acid. 

This  result  is  of  no  little  importance  i-n  the  treatment  of  the 
gouty  diatheses.  With  a  kidney  permeable  to  uric  acid  as  it  is 
in  uncomplicated  gout,  the  purins  may  be  made  to  come  to  both 
complete  oxidation  and  complete  excretion.  The  increase  in 
the  alkalescence  of  the  blood  and  body  tissues  also  resulting 
from  cold  applications  greatly  favors  these  changes. 

The  condition  in  uratic  diathesis  in  reality  consists  of  an 
accumulation  of  all  the  purin  bodies  (uric  acid  plus  bases). 
Because  of  this  Kolisch  proposed  the  term  "purin  diathesis" 
instead  of  uric  acid  diathesis.  The  excretion  of  the  bases 
exercises  a  deleterious  effect  upon  the  kidneys,  and  the  altered 
kidney  is  in  turn  less  capable  of  excreting  basic  purin.  This 
vicious  circle  would  be  done  away  with,  were  the  bases  excreted 
in  a  more  completely  oxidized  state,  i.  e.,  as  uric  acid.  As 
remarked  by  Strasser,  tonic  hydrotherapy  breaks  through  this 
vicious  circle  and  completely  changes  the  aspect  of  purin  auto- 
intoxication. The  excretion  of  a  waste,  not  as  such,  but  in  an 
altered  and  less  toxic  state  may  be  considered  ' '  the  removal  of 
poison  par  excellence." 

Extractives.  A  summary  of  the  relation  of  the  nitrogenous 
extractives  to  the  total  nitrogen  shows  that  they  constitute 
respectively  3.86  per  cent  in  the  preperiod,  2.17  per  cent  in  the 
bath  period  and  0.56  per  cent  in  the  after-period.  As  already 
mentioned,  on  the  third  bath  day  they  disappear  entirely  and 
urea,  uric  acid,  and  ammonia  claim  the  whole  nitrogen  for 
themselves. 


PHOSPHORUS 


119 


Phosphoric  Acid.  The  phosphorus  of  the  urine  arises  from 
certain  proteids  in  common  with  nitrogen  and  hence  gives  an 
added  index  to  the  processes  of  proteid  metabolism.  Strasser's 
experiments  reveal  an  increased  absorption  of  phosphorus  as 
well  as  of  nitrogen,  as  shown  by  the  decrease  in  fecal  phosphorus 


Fig.  35.    Showing  effect  of  cold  treatment  on  the  alkaline  and 
earthy  phosphates,     (Strasser.) 


during  the  bath  period  and  an  equal  and  simultaneous  increase 
in  urinary  phosphorus.  The  absolute  increase  in  the  phos- 
phoric acid  of  the  urine  reached  a  maximal  height  of  28  per 
cent  on  the  second  bath  day.  Compared  with  the  total  nitro- 
gen, there  is  also  a  relative  increase  as  shown  in  Fig.  33.  This 
relative  increase  may  be  accounted  for  by  the  fact  that  phos- 


ISO  NITROGENOUS  METABOLISM 

phorus  comes  from  lecithin  as  well  as  certain  proteids.  In  the 
first  experiments  the  relative  increase  lasted  throughout  the 
whole  of  the  after-period.  It  is  significant  that  only  the  more 
labile  phosphates  take  part  in  the  increase.  This  increase  in 
urinary  phosphorus  is  wholly  in  the  alkaline  phosphates,  the 
earthy  phosphates  remain  unchanged  (Fig.  35.}. 

Sulphates  and  Chlorides.  The  sulphur  of  the  urine  also  comes 
from  proteid  substances  and  the  urinary  sulphates  are,  therefore, 
another  end  product  of  proteid  metabolism  and  should  increase 
with  the  nitrogen.  The  average  increase  was  10.4  per  cent 
during  the  bath  period,  which  height  was  maintained  during 
nearly  the  whole  of  the  after-period.  The  increase  in  the  sul- 
phates was  almost  entirely  in  the  mineral  sulphates,  the  ethe- 
real sulphates  suffering  but  a  trifling  change.  This  might  be 
expected  since  more  complete  digestion  and  assimilation  of  pro- 
teid, together  with  completer  oxidation,  would  tend  to  decrease 
putrefactive  changes  and  so  lessen  the  relative  amount  of  ethe- 
real sulphate.  Hawk  observed  decreased  intestinal  putrefaction 
as  a  result  of  copious  water-drinking.  This  result  was  measured 
by  the  indican  output.  It  seemed  to  be  due  to  more  complete 
intestinal  absorption. 

The  increase  in  the  excretion  of  sodium  chloride  was  chiefly 
on  the  first  bath  day  (15  per  cent)  and  did  not  outlast  the  bath 
period.  The  excretion  of  sodium  chloride  in  oedema  is  a  matter 
of  no  little  importance.  In  this  condition  hydriatic  applications 
produce  an  increase  in  chloride  excretion  in  two  ways;  first, 
by  increasing  the  absorption  of  interstitial  fluid,  and  second,  by 
stimulating  kidney  activity. 

EFFECTS  OF  HEAT 

The  reported  researches  regarding  the  effects  of  heat  upon 
metabolism  are  somewhat  conflicting  in  their  results.  This  is 
doubtless  due  to  differences  in  the  mode  of  application,  the  in- 
tensity, duration,  and  frequency  of  repetition  of  the  treatment 
as  well  as  in  the  reactive  response  of  the  organism.  Formanek 
observed  that  a  single  hot  bath  scarcely  changed  the  nitrogen, 
but  after  two  or  more  such  baths  on  successive  days  there 
occurred  a  decided  increase  of  nitrogen  elimination.  It  would 


EFFECTS  OF  HEAT  121 

seem  that  a  single  hot  bath,  if  not  too  prolonged,  should  de- 
crease the  elimination  of  nitrogen  for  the  time-being,  as  a 
result  of  the  atonic  reaction  and  the  lessened  amount  of  water 
excreted  by  the  kidney. 

In  general  this  agrees  with  the  results  obtained  by  two  differ- 
ent observers,5  one  working  with  the  Turkish  bath  and  one 
with  the  Russian  bath. 

Effects  of  Turkish  Bath  at  122°  F.  for  50  Minutes 

Day  before  Bath  Day  of  Bath 

Amount  of  urine  24  hours  -      1,567.  c.  c.  950.  c.  c. 

Specific  gravity                              1,018.8  1,027. 

Urea                                                       45.47  gm.  39.9  gm. 

Uric  acid  -                                              0.683  gm.  0.860  gm. 

Effects  of  Russian  Bath  at  113°  F.  for  25  Minutes 

Day  before  Bath  Day  of  Bath 

Amount  of  urine  24  hours  -      1,683.  c.  c.  900.  c.  c. 

Specific  gravity                               1,021.  1,027. 

Urea      -                                                  52.68  gm.  38.7  gm. 

Uric  acid  -                                               0.858  gm.  0.980  gm. 

Bastels,  Naunyn,  and  Schleich  found  an  increase  of  urea 
and  total  nitrogen  excretion  which  later  showed  diminution. 
It  is  altogether  possible  that  these  opposite  results  may  also  be 
accounted  for  by  the  differences  in  the  amount  of  water  in- 
gested by  the  subjects  during  the  respective  experiments.  Loss 
of  water  through  sweating  decreases  the  tissue  fluids  and  there- 
fore the  urinary  solvent,  if  this  loss  is  not  replaced  by  water- 
drinking.  It  has  been  shown  by  Hawk 6  that  copious  water- 
drinking  increases  the  excretion  of  nitrogen  in  the  form  of  urea, 
due  to  the  washing  out  from  the  tissues  of  preformed  urea.  He 
also  observed  a  greater  phosphorus  excretion.  The  maximum 
increase  occurred  regularly  on  the  second  day  of  the  experi- 
ment. 

The  secondary  diminution  in  the  nitrogen  excretion  observed 
by  Schleich  would  tend  to  show  that  the  metabolized  nitrogen 
in  the  case  of  hot  baths  comes  more  from  the  tissue  albumen 
than  from  any  increase  in  the  intestinal  absorption  of  proteids. 

5  Hinsdale-Hydrotherapy,  pp.  22,  23. 

6  University  of  Pennsylvania  Medical  Bulletin,  1905. 


122  NITROGENOUS  METABOLISM 

In  case  prolonged  hot  applications  increase  the  efficiency  of 
absorption,  there  should  be  a  gradual  return  of  the  curve  of  in- 
creased excretion  to  the  normal.  Instead  of  this,  lessened  ex- 
cretion occurs  in  an  effort  to  restore  the  nitrogen  balance .  This 
also  agrees  with  clinical  experience.  A  course  of  hot  baths 
unaccompanied  by  the  tonic  of  cold  applications  results  in  loss 
of  weight.  It  is  true  this  is  largely  a  loss  of  fat,  but  the  tissue 
proteids  are  also  concerned  in  the  increased  oxidation. 

All  observers  seem  to  agree  that  the  excretion  of  uric  acid  is 
increased  by  hot  baths.  This  being  true,  both  hot  and  cold 
baths  should  be  useful  in  gout. 

EFFECTS  ON  LOW  PROTEID  DIET 

Strasser's  experiments  were  all  conducted  upon  individuals 
subsisting  upon  a  high  proteid  diet — 122  grams  of  proteid.  In 
May  of  1912  Prof.  E.  H.  Risley7  conducted,  at  the  request  of 
the  writer,  a  series  of  experiments  to  determine  the  effects  of 
stimulating  hydriatic  procedures  upon  the  nitrogen  metabolism 
of  healthy  individuals  subsisting  upon  a  low  proteid  diet 
(Chittenden  standard) . 

Six  medical  students  were  chosen.  The  diet  contained  daily 
61  grams  of  proteid  and,  including  carbohydrate  and  fat,  pos- 
sessed a  total  calorific  value  of  2,525  calories.  As  all  were 
accustomed  to  a  non-flesh  dietary,  this  was  no  great  change 
from  their  usual  fare.  The  excretions  for  the  first  day  of  the 
standard  diet  were  discarded.  For  the  nine  days  following, 
estimations  were  made  of  the  quantity,  specific  gravity,  acidity, 
urea,  ammonia,  creatinin,  uric  acid,  total  purin,  and  total  nitro- 
gen of  the  urine;  also  the  total  nitrogen  of  the  feces. 

The  preperiod,  the  treatment  period,  and  the  after-period 
each  lasted  three  days.  During  the  treatment  period,  three 
treatments  daily  were  administered  to  each  man.  These  were 
as  follows:  At  6:30  A.  M.  was  given  a  cold  shower  or  spray,  or 
a  hot  and  cold  shower,  with  temperatures  according  to  the 
ability  of  the  individual  to  react.  The  forenoon  treatment  at 
10  A.  M.  consisted  of  an  alternate  hot  and  cold  leg  bath,  with 

\-  E'  H^Rlsley-  M-  D-.  formerly  professor  of  chemistry  in  the  College  of  Medical  Evan- 
sts.     Doctor  Risleys  long  experience  in  studies  in  diet  and  metabolism  assures  the 
accuracy  of  the  results. 


LOW  PROTEID  DIET  123 

three  changes  of  heat  and  three  of  cold.  The  hot  leg  bath  was 
administered  at  116° — 125°  F.  for  two  minutes,  and  the  cold  at 
58° — 60°  F.  for  twenty  seconds.  This  was  followed  by  a  dripping 
sheet  rub,  the  sheet  being  wrung  from  a  pail  of  water  at  60°  F. 
and  the  pail  pours  being  given  at  55°  and  50°  F.  respectively. 
The  afternoon  treatment  at  4  p.  M.  consisted  of  an  alternate 
hot  and  cold  percussion  douche  to  the  spine  and  legs.  The  hot 
was  given  at  116°— 125°  F.  and  the  cold  at  60°  F.  This  was 
followed  by  a  cold  shallow  bath  at  60°  F.  the  usual  procedure 
being  given  twice  and  the  bath  lasting  altogether  about  four 
minutes. 

In  all  cases  except  one  the  men  maintained  their  weight. 
This  individual  appeared  to  have  overstocked  with  nitrogenous 
food  and  the  loss  of  four  pounds  in  weight  and  the  change  of 
diet  was  accompanied  by  an  increased  feeling  of  well  being — 
he  felt  ' '  brighter  in  every  way. ' ' 

The  results  as  obtained  by  averaging  the  analyses  for  all  six 
men  showed  no  remarkable  changes  in  the  excretion  of  nitrogen 
nor  in  any  of  the  nitrogen-containing  urinary  constituents, 
except  possibly  in  the  purin,  in  either  the  treatment  period  or 
the  after-period.  With  the  exception  of  purin,  in  which  there 
was  a  considerable  decrease,  the  fluctuations  were  all  minimal. 
The  changes  in  fecal  nitrogen  were  also  small.  The  results 
can  be  explained  upon  no  other  basis  than  that  the  diet  supplied 
but  little  surplus  nitrogen.  Neither  was  the  system  (except 
in  the  one  case  referred  to)  stocked  with  unnecessary  nitrogen 
which  might  be  siezed  upon  by  the  oxidizing  effect  of  the  ther- 
mic stimulation.  Even  the  extreme  stimulating  measures  re- 
sorted to  failed  to  change  greatly  the  accustomed  nitrogen 
metabolism  of  the  individuals  under  experiment.  All  or  nearly 
all  of  the  urinary  nitrogen,  as  well  as  the  ratios  in  nitrogen 
partition  must  be  regarded  as  the  result  of  usual  and  normal 
metabolism,  i.  e.,  as  necessary  conditions  in  healthy  persons 
subsisting  upon  a  low  proteid  diet. 

These  studies  are  helpful  in  explaining  the  significance  of 
the  results  obtained  by  Strasser  in  whose  experiments  the  diet 
contained  an  excess  of  61  grams  of  proteid  and  hence  nitrogen 
which,  not  being  required  by  the  body,  was  subject  to  large 


Ig4  NITROGENOUS  METABOLISM 

changes  without  encroaching-  at  all  upon  the  more  stabile  or 
necessary  nitrogen  required  by  normal  body  functions.  It  is, 
therefore,  to  be  confidently  expected  that  hydrotherapeutic 
measures  should  have  their  greatest  effects,  both  qualitatively 
and  quantitatively,  in  disorders  of  proteid  metabolism  and  in 
individuals  who  have  for  years  been  accustomed  to  a  high 
proteid  diet,  i.  e.,  an  excessive  ingestion  of  nitrogen. 

This  view  of  the  matter  is  entirely  consistent  with  the  fact 
that  the  nitrogen  of  the  food  does  not  serve  primarily  as  fuel 
for  the  supply  of  energy,  but  is  utilized  in  tissue  building  and  in 
tissue  repair.  Neither  changes  in  season  nor  in  the  amount  of 
muscular  work  produce  appreciable  changes  in  the  metabolism 
of  tissue  nitrogen.  On  the  other  hand  changes  in  season  and 
the  amount  of  muscular  work  performed  produce  large  changes 
in  the  amount  of  'non-nitrogenous  food  required.  Likewise 
thermic  and  mechanical  stimulation  produce  most  conspicuous 
changes  in  carbonaceous  metabolism.  It  is  to  these  changes 
we  shall  now  turn  our  attention. 


CHAPTER  XII 

RESPIRATION,  RESPIRATORY  CHANGES 
AND  CARBONACEOUS  METABOLISM 

IN  THE  previous  chapter,  we  have  considered  tissue  change 
solely  from  the  standpoint  of  proteid  metabolism  and  chiefly 
as  regards  the  nitrogenous  moiety.  There  remains  of  course 
a  certain  amount  of  carbohydrate  when  urea  is  spilt  off  from  the 
proteid  molecule,  also  the  carbohydrate  taken  as  such  and  the 
fat,  all  of  which  contain  no  nitrogen.  Their  metabolism  is  so 
intimately  associated  with  respiratory  interchanges  that  we  shall 
consider  them  together;  the  respiratory  excretion  being  quite 
as  much  a  guide  to  these  changes  as  is  renal  excretion  to 
nitrogenous  changes. 

RESPIRATORY  EFFECTS 

We  have  noted  that  all  sorts  of  stimuli  applied  to  the  skin 
produce  more  or  less  pronounced  vasomotor  and  cardiac 
changes,  through  reflex  action.  The  respiration  is  more 
readily  affected  by  cutaneous  stimuli  than  is  any  other  function. 
One  of  the  most  efficient  means  of  resuscitating  the  new  born 
infant  is  the  use  of  heat  and  cold.  The  same  method,  i.  e.,  the 
alternate  application  of  heat  and  cold  to  the  chest,  is  scarcely 
less  effective  in  the  adult.  The  sudden  application  of  either 
extreme  heat  or  cold,  especially  if  accompanied  by  percussion, 
produces  an  initial  deep  respiration,  which  is  almost  as  suddenly 
interrupted,  this  being  followed  by  other  spasmodic  efforts,  so 
that  the  respiration  assumes  a  staccato  type.  With  prolonged 
applications  of  either  heat  or  cold,  the  respiration  soon  becomes 
regular,  the  rate  and  depth  depending  upon  the  temperature  of 
the  application. 

(125) 


126  CARBONACEOUS  METABOLISM 

Kellogg:  records  the  following:  experiments l  as  illtistrative  of 
the  effect  of  thermic  stimuli  upon  the  volume  of  tidal  air. 
To  a  subject  whose  tidal  air  measured  28  cubic  inches,  a  wet 
sheet  rub  at  40°  F.  was  administered.  Immediately  after  the 
treatment,  the  tidal  air  measured  35  cubic  inches,  an  increase 
of  nearly  26  per  cent. 

To  another  subject,  with  an  initial  tidal  air  volume  of  33 
cubic  inches,  a  cold  mitten  friction  was  administered  at  45°  F. 
Immediately  after,  the  tidal  air  measured  51  cubic  inches,  an 
increase  of  55  per  cent. 

In  a  third  subject  the  amount  of  tidal  air  before  the  treat- 
ment was  27  cubic  inches.  A  wet  sheet  pack  wrung  from 
water  at  45°  F.  was  applied  and  continued  for  one  hour.  After 
the  initial  warming-,  the  pack  was  kept  at  the  neutral  stage. 
Two  minutes  after  the  sheet  was  applied,  the  volume  of  the 
tidal  air  was  36  cubic  inches,  an  increase  of  33  1-3  per  cent. 
In  15  minutes  it  was  33  cubic  inches.  The  volume  gradually 
decreased  until  at  the  end  of  the  hour  it  was  28  cubic  inches. 
During  the  entire  period,  there  was  an  average  increase  of 
18  1-2  per  cent. 

In  a  fourth  subject  a  heating  compress  wrung  from  ice 
water  was  applied  to  the  chest  only.  The  tidal  air  immedi- 
ately rose  from  507  c.  c.  to  751  c.  c.,  an  increase  of  48  per 
cent.  At  the  end  of  20  minutes  the  tidal  air  measured  604  c.  c., 
20  per  cent  more  than  at  the  beginning.  The  average  increase 
was  170  c.  c.,  or  33  per  cent. 

Another  subject,  whose  tidal  air  was  43  cubic  inches,  was 
immersed  in  a  hot  bath  at  108°  F.  After  12  minutes  the  tidal 
air  had  decreased  to  27  cubic  inches,  or  a  decrease  of  37.2  per 
cent.  Ten  minutes  after  the  bath,  it  had  risen  to  33  cubic 
inches;  30  minutes  after,  to  37  cubic  inches.  The  loss  in  the 
volume  of  respired  air  amounted  to  37  1-2  per  cent. 

.Brief,  sudden  applications  of  cold  produce  spasmodic  respira- 
tion. The  reaction  to  cold  applications  is  accompanied  by  a 
slowed  rate  and  greater  depth  of  respiration,  as  shown  by  the 
above  experiments.  The  rate  is  slowed  and  the  amplitude  of 
movement  increased  in  proportion  to  the  completeness  of  reac- 
tion. 


1    Rational  Hydrotherapy.  pp.  1122,  1133. 


GASEOUS  INTERCHANGE  127 

Warm  baths  or  hot  moist  applications  to  the  chest  increase 
the  ease  of  respiration,  at  the  same  time  somewhat  increasing 
the  rate.  Long,  hot  baths  produce  frequent,  shallow  breathing. 
Here  again  the  conflicting  results  which  have  been  reported  are 
doubtless  due  to  varying  modes  of  applying  the  hot  applications, 
also  to  the  degree  and  duration  of  the  heat.  The  inhaling  of 
dry  air  produces  difficult  breathing.  This  may  be  due  to  the 
drying  of  the  membranes,  thus  compelling  deeper  or  more  fre- 
quent respiration  in  order  to  obtain  the  same  amount  of  oxygen. 
Inhalations  of  steam  greatly  facilitate  respiration.  It  is  decid- 
edly beneficial  in  almost  all  forms  of  dyspnoea.  The  moisture 
favors  gaseous  interchange,  while  the  heat  dilates  the  blood- 
vessels, thus  increasing  the  surface  presented  for  the  inter- 
change. The  steam  may  be  made  the  vehicle  of  some  volatile 
drug,  so  enhancing  its  antidyspnoeic  properties. 

The  rule  then  prevails  that  cold  applications  increase  the 
amplitude  of  the  respiratory  movement,  i.  e.,  the  depth  of  res- 
piration and  the  volume  of  tidal  air.  The  breathing  of  fresh 
cold  air  produces  the  same  result.  This  being  the  case,  cold 
applications  to  the  skin  surface,  especially  to  the  chest,  also  the 
breathing  of  cold  air  should  be  of  great  service  in  all  febrile 
conditions  since  oxygen  absorption  and  oxidative  changes  are 
much  interfered  with  in  fever. 

Hot  applications  decrease  the  amplitude  of  the  respiratory 
movement  and  the  volume  of  the  tidal  air,  while  moist  heat 
greatly  aids  in  gaseous  interchange  and  thus  eases  difficult  res- 
piration. Such  applications  are,  therefore,  of  great  service  in 
painful  dyspnoea,  especially  in  pleurisy  as  a  means  of  lessening 
the  respiratory  excursion. 

GASEOUS  INTERCHANGE 

Having  considered  the  physical  changes  in  respiration,  we 
may  pass  to  the  alterations  observed  in  the  chemical  activities 
of  the  respiratory  function.  Since  it  has  been  shown  that  both 
hot  and  cold  baths  increase  nitrogenous  metabolism,  we  might 
expect  the  same  effects  upon  the  oxidation  of  carbonaceous 
material.  This  is  precisely  what  occurs. 


128  CARBONACEOUS  METABOLISM 

Rubner2  (1903)  has  given  us  some  observations  which  are  of 
a  very  practical  nature,  since  the  results  obtained  were  after 
hot  and  cold  applications  given  as  they  are  ordinarily  applied 
in  practice.  The  following  table  shows  the  effect  of  short  baths 
upon  the  consumption  of  oxygen  and  the  elimination  of  carbon 
dioxide: — 


Bath 

at 

Volume  of  Air 

C02 

02 

Resp. 

Quot.:; 

61° 

F. 

plus 

22 

.9% 

plus 

64 

.8% 

plus  46 

.8% 

0.86: 

:  1.00 

86° 

F. 

'  * 

7. 

3 

1  ' 

31 

.0 

16 

.2 

0.95  : 

:  0.93 

91° 

F. 

'  ' 

1. 

8 

minus 

1 

.8 

6 

.2 

0.87  : 

:  0.90 

104° 

F. 

i  < 

16. 

1 

<  t 

3 

.9 

11       3 

.2 

0.86  : 

0.90 

111° 

F. 

t  < 

18, 

8 

plus 

32 

.1 

"     17 

.3 

0.86  : 

:  1.00 

H.  Winternitz  (1899)  in  seven  experiments  upon  the  same 
individual,  observed  that  hot  baths  continued  30  minutes  pro- 
duce during  that  time  an  average  increase  in  the  consumption 
of  oxygen  amounting  to  78  per  cent  and  in  CC>2  elimination  of 
91  per  cent.  Observations  made  on  an  average  nearly  an  hour 
after  the  bath,  still  revealed  an  increase  of  22  per  cent  in  the 
oxygen  consumed  and  16  per  cent  in  CO2  exhaled.  Rubner 
has  shown  that  metabolism  is  at  a  minimum  under  temperatures 
from  91.4°  to  95°  F.  (33°  to  35°  C.).  A  fall  of  every  1°  C.  in 
the  surrounding  temperature  increases  metabolism  by  2  or  3 
per  cent. 

From  the  above  observations  we  may  deduce  the  law  thaf 
applications  below  the  skin  temperature  increase  respiratory 
changes  in  proportion  to  the  degree  of  cold.  Neutral  tempera- 
tures exert  but  little  influence.  Temperatures  above  that  of 
the  skin  surface  again  increase  the  respiratory  function  in  pro- 
portion to  the  degree  of  heat. 

Rubner4  found  in  his  experiments  that  a  douche  produced 
more  than  double  the  change  produced  by  a  bath  at  the  same 
temperature,  each  continued  for  the  same  length  of  time,  viz., 
3  1-2  to  5  minutes.  The  accompanying  table  shows  the  increase 
in  per  cent. 


2  Archiv  fur  Hygriene,  1903.  Bd.  46. 

3  The  normal  respiratory  quotient 
:en  inhaled  by  the  amount  of  carbon  i 

4  Archiv  fflr  Hygiene.  1903.  Bd.  46.  p.  390. 


3    The  normal  respiratory  quotient  is  0.9  and  is  found  by  dividing  the  amount  of  oxy- 
gen inhaled  by  the  amount  of  carbon  dioxide  exhaled. 


MECHANICAL  STIMULI  129 

Douche  at  61°  F.  Bath  at  61°  F. 

Volume  of  air  plus    54.5%     -  plus  22.9% 

CO2  exhaled  "149.4  "64.8 

O  consumed  110.1  "    46.8 

These  observations  prove  the  immense  advantage  of  mechani- 
cal stimuli  combined  with  thermic  and  also  of  exercise  follow- 
ing: hydriatic  treatment,  especially  when  taken  in  the  open  air. 
A  swimming  bath  or  cold  rubbing  bath  produces  more  decided 
tissue  change  than  quiet  immersion  for  the  same  reason.  The 
same  is  true  of  massage  following  baths  of  whatever  tempera- 
ture. At  Aix-les-Bains  a  specialty  is  made  of  what  is  called 
the  massage  douche.  This  consists  of  deep-kneading  of  the 
muscles  given  while  one  or  more  streams  of  water  are  pouring 
over  the  parts  treated.  The  Turkish  shampoo  following  a 
Turkish  or  Russian  bath  also  combines  many  of  the  procedures 
of  massage,  and  is  very  popular  with  the  obese.  All  such 
combinations  of  extreme  thermic  with  vigorous  mechanical 
stimulation  are  of  great  advantage  in  the  treatment  of  obesity 
since  the  resultant  oxidation  of  carbon  compounds  is  more  than 
double  that  produced  by  thermic  stimulation  alone.  The  lung 
gymnastics  produced  by  hydriatic  applications  are  by  no  means 
the  least  important  factor  in  the  results  produced  by  hydro- 
therapy. 


CHAPTER  XIII 
MUSCULAR  CAPACITY 

restorative  effect  of  warm  baths  in  relieving-  the  sense 
1  of  fatigue,  and  the  tonic  effect  of  the  cold  douche  or  spray 
in  overcoming  the  effects  of  fatigne,  are  familiar  to  all  who  are 
acquainted  with  the  practical  application  of  hydriatic  proced- 
ures. These  effects  are  extensively  used  by  athletes  in  over- 
coming the  exhaustion  of  severe  or  prolonged  exertion.  And 
medically  considered,  they  are  by  no  means  the  least  impor- 
tant of  the  results  obtained  by  hydriatic  applications. 

In  1892  and  1893  Vinaj  and  Maggiori  *  reported  a  series  of 
experiments  undertaken  to  show  the  effect  of  hydriatic  meas- 
ures upon  the  capacity  of  the  muscles  for  work  and  their  resist- 
ance to  fatigue.  These  investigations  were  made  with  Mosso's 
ergograph  {Fig.  36.).  This  instrument  is  so  constructed  as  to 
hold  the  hand  and  forearm  stationary  in  the  body  of  the  appa- 
ratus, while  one  finger  is  left  free  for  flexion  and  extension. 
The  forefinger,  or  middle  finger,  is  usually  employed  so  that, 
by  means  of  a  cord  over  a  pulley,  it  raises  and  lowers  a  weight. 
This  is  kept  up  until  the  muscles  are  fatigued  and  unable  to 
contract  longer.  A  writing  point  makes  a  graphic  record  on 
the  drum  of  an  upright  or  horizontal  kymograph.  Their  ex- 
periments were  done  with  a  weig-ht  of  three  or  four  kilograms, 
raised  every  two  seconds. 

In  one  experiment  (Fig.  37 A.)  the  middle  finger  of  the  right 
hand  was,  under  normal  conditions,  able  to  execute  fifty  con- 
tractions, representing  a  work  of  5.139  kilogrammeters.  After 
a  cold  bath  at  50°  F.  for  fifteen  seconds  the  same  group  of 
muscles  executed,  before  fatigued,  seventy-four  contractions 
representing  a  work  of  9.126  kilogrammeters  (Fig.  37  B.*). 

1    Blfttter  fUr  klinische  Hydrotherapie. 
(130) 


COLD  TREATMENT  131 

A  graduated  bath  beginning-  at  96°  F.  and  ending-  at  68°  F. 
increased  the  number  of  contractions  from  thirty-nine,  repre- 
senting- a  work  of  3.603  kilogrammeters ,  to  eighty -seven  con- 
tractions, the  equivalent  of  9.349  kilogrammeters  of  work 
(Fig.  38.}. 

When  the  muscles  are  already  fatigued  from  active  work,  by 
cold  applications  they  may  be  restored  to  their  usual  power. 
This  restorative  effect  is  well  illustrated  in  Figs.  39  and  40. 


Fig.  36.    Mosso's  Ergograph. 

In  Fig.  39  the  first  tracing  (A)  represents  the  fatigue  curve 
of  the  normal  muscle.  The  second  (/?)  is  the  fatigue  curve 
taken  following  active  work,  i.  e.,  at  a  time  when  muscular 
capacity  has  already  been  partially  exhausted.  The  third  trac- 
ing- (O  shows  the  restorative  effect  of  a  graduated  bath  given 
following  the  fatig-ue  of  active  work.  In  the  case  of  the  cold 
wet  sheet  rub  following  fatigue  {Fig.  40C.}  the  muscular  capac- 
ity has  been  increased  to  a  point  even  above  the  normal. 


ist 


MUSCULAR  CAPACITY 


With  hot  baths  the  opposite  effects  prevail.  There  is  a  de- 
cided lessening:  of  the  muscular  capacity,  amounting  in  one  of 
Kellogg's  experiments  to  a  decrease  of  44  per  cent.  His  ex- 
periments cover  a  wide  range  and  are  very  instructive.  He 
used  both  Mosso's  ergograph  and  the  dynomometer;  the  latter 
a  machine  of  his  own  design.  The  following  table  is  compiled 
from  his  experiments  with  Mosso's  ergograph: — 2 


Subject 


Hot  Treatment 


Cold  Treatment 


21        140 
26        150 
Xot  stated 

STRENGTH 

4.994           Spr.  113° 
5.395 
1.312               D.  115° 

TIME 

15  Min. 
5Min. 

4.432 
0.927 

Spr.  60° 
D.  60° 
D.55° 

10 
1 
15 

Min. 
Min. 
Sec. 

6.094 
6.925 
1.527 

26 

151 

8.282 

I), 

60° 

3 

Min. 

11.966 

26 

151 

6.371 

Gen.  D.  112° 

15  Min. 

4.155 

Gen. 

I) 

56° 

15 

Sec. 

8.448 

26 

151 

8.033 

B.  104° 

20  Min. 

4.459 

26 

151 

5.817 

Gen. 

D. 

55° 

15 

Sec. 

8.642 

26 

151 

5.817 

Neutral  bath 

5.789 

21 

140 

5.761 

Shal. 

B. 

65° 

2 

Min. 

7.589 

4.791 


W.  S.  P.  60°        20  Min.       5.456 


Fig.  37.    Fatigue  curve  of  right  hand.    A— normal,    B— after 
bath  at  50°  F.  for  fifteen  seconds. 

Considering  both  the  dynomometer  and  ergograph  experi- 
ments, there  was,  after  cold  procedures,  an  average  gain  in 
muscular  capacity  of  about  thirty  per  cent,  and  after  hot  appli- 
cations, an  average  loss  of  thirty  per  cent  in  the  work  accom- 
plished. Cold,  therefore,  increases  the  muscular  working 
capacity;  while  warmth,  not  combined  with  mechanical  effects, 
diminishes  muscular  power.  After  fatigue  a  simple  warm  bath 
may  slightly  increase  muscular  power,  although  this  effect  is 

2    Recorded  in  Rational  Hydrotherapy. 


MECHANICAL  STIMULI 


133 


not  decided  (.Fig.  41  A.}.  Warm  procedures  when  combined 
with  friction  or  percussion,  as  in  douches,  produce  an  increase 
in  muscular  power  (fig-.  41C.),  but  to  a  less  extent  than  cold. 
In  practice  alternate  hot  and  cold  douches,  when  so  given  that 


A  B 

Fig.  38.    Fatigue  curve.    A — before,     B — after  graduated 
bath,96°to6ff>  F. 


A  B  C 

Fig.  39.  Effect  of  work  and  graduated  bath  upon  fatigue 
curve.  A — normal,  B — after  active  work.  C — after  work 
followed  by  bath. 

the  hot  is  short  and  used  only  to  prepare  the  body  for  cold, 
produce  the  greatest  increase  in  the  working  power.  Mechani- 
cal effects  alone,  such  as  massage,  also  raise  the  working" 
capacity  of  the  muscles  but  to  a  less  extent  than  cold  proced- 
ures. 


134  MUSCULAR  CAPACITY 

To  what  are  these  tonic  and  restorative  effects  due?     This 
question  may  be  somewhat  difficult  to  answer;   but  it  would 


A  B  c 

Fig.  40.  Effect  of  labor  and  cold  wet  sheet  rub  upon  fatigue 
curve.  A— normal.  B — after  labor.  C — after  labor  followed 
by  wet  sheet  rub. 


A  B  C 

Fig.  41.    Effect  of  simple  warm  bath  and  of  warm  douche  on 
tigued  muscles.     A— muscular  fatigue    followed    by  warm 

bath.    B— after  fatigue  only.    C— after    fatigue    followed  by 

warm  douche. 

seem  that  the  restoration  of  the  muscle  to  its  normal  working- 
power  is  due  to  more  than  one  change.  Among  these  changes 
may  be  mentioned  the  restoration  of  tone  to  the  nerve  and  its 


FATIGUE  POISONS  135 

central  cell  brought  about  by  the  cold  application.  It  is  prob- 
ably due  •  also  to  washing  out  and  oxidizing-  of  the  fatigue 
poisons  consequent  on  the  quickening-  of  the  circulation;  and 
third  to  the  return  of  the  blood  to  a  condition  of  more  normal 
alkalinity. 

FATIGUE  POISONS 

The  last  two  of  these  changes  deserve  more  than  passing 
mention.  Experimental  fatigue  due  to  contractions  of  excised 
muscle  is  accompanied  by  an  increase  of  lactic  acid,  while 
freshly  excised  resting  muscle  yields  very  small  quantities  of 
lactic  acid.  So  far  as  at  present  demonstrated  lactic  acid  is  the 
chief  substance  normally  produced  in  fatigued  muscle.  This  of 
course  gives  rise  to  a  lessening  in  the  alkalinity  of  the  blood 
flowing  from  such  fatigued  muscles.  In  the  presence  of  an 
abundant  supply  of  oxygen  this  lactic  acid  disappears.  We 
have  already  learned  that  these  acidifying  substances  also  dis- 
appear under  the  stimulus  of  cold  procedures,  due  to  an  in- 
crease in  oxidation. 

On  the  contrary,  heating  procedures  are  conducive  to  acidifi- 
cation as  also  already  shown  in  the  previous  chapter.  Con- 
firmatory of  this  is  the  following  statement  from  Fletcher  and 
Hopkins:3  '  The  amount  of  lactic  acid  produced  in  full  heat- 
rigor  is  constant  for  similar  muscles.  This  'acid  maximum' 
of  heat-rigor  is  not  affected  by  a  previous  appearance  within 
the  excised  muscle  of  lactic  acid  due  to  fatigue,  or  by  a  previous 
disappearance  of  acid  in  the  presence  of  oxygen,  or  by  alter- 
nate appearances  and  disappearances  several  times  repeated." 

It  is  thus  amply  demonstrated  that  lactic  acid  is  a  fatigue 
poison.  Procedures  which  cause  its  disappearance  bring  about, 
by  this  disappearance,  a  restoration  or  heightening  of  muscular 
power.  On  the  contrary,  procedures  which  increase  the  lactic 
acid  content  of  muscles  do  by  this  increase  bring  on  the  phe- 
nomena of  fatigue,  and  so  lessen  muscular  capacity. 

There  is  some  clinical  evidence  which  goes  to  show  that  lactic 
acid  is  not  the  only  substance  which  may  cause  the  appearance 
of  fatigue.  Certain  products  of  nitrogenous  metabolism  and 


3    Quoted  from  "Further  Advances  in  Physiology,"  edited  by  Leonard  Hill,  p.  214. 


136 


MUSCULAR  CAPACITY 


particularly  of  the  metabolism  of  nuclear  proteid  seem  to  exer- 
cise the  same  effect.  Since  the  amount  of  these  from  the 
organism  itself  is  small  and  fairly  constant  the  effects  are  most 
apparent  in  the  case  of  ingestion  of  much  purin  with  the  food 
(exogenous  purin).  The  premature  appearance  of  fatigue  in 
meat  eaters  and  users  of  coffee  and  tea  is  scarcely  to  be 
accounted  for  on  any  other  basis. 

It  is  a  well  known  fact  that  the  fatigue  curves  of  vegetarians 
reveal  a  high  degree  of  ability  to  sustain  continuous  and  pro- 
longed effort;  while  on  the  contrary  the  fatigue  curves  of  meat 
eaters  show  a  great  susceptibility  to  fatigue,  and  hence  its  early 
onset  in  endurance  tests.  Buttner's  recent  compilation  of 


u 


too 

CO/CTRACTlOnS 


AF-TEE    ESO          AF-Tee  <oo 

CO/VTieACTlO/tS      COMTEACTIOM3 


Fig.  42.  The  effects  of  caffeine  on  voluntary  muscle.  The  two 
tracings  are  from  the  two  gastrocnemii  of  a  frog.  The  muscle 
which  recorded  the  upper  one  was  kept  in  a  physiologic  salt 
solution,  the  lower  one  in  a  dilute  solution  of  caffeine.  (Wood.) 

experimental  work  in  this  line  in  his  treatise  on  "A  Fleshless 
Diet "  leaves  no  question  as  to  the  finality  of  these  conclusions. 
The  data  there  given  are  most  interesting  and  important  and 
should  claim  the  attention  of  all  who  undertake  to  advise  or 
prescribe  in  matters  dietetic. 

That  the  early  onset  of  fatigue  in  meat  eaters  and  coffee 
users  is  due  largely  or  wholly  to  purin  substances  is  very  well 
shown  by  the  experiments  of  H.  C.  Wood,  Jr.4  He  experi- 
mented with  the  voluntary  muscle  of  a  frog,  using  a  solution  of 

4    Pharmacology  and  Therapeutics,  p.  36. 


THERAPEUTIC  APPLICATION  137 

caffeine  (trimethyl  xanthin)  which  is  one  of  the  basic  purins. 
The  result  was  at  first  an  increased  height  of  the  muscular  con- 
traction and  hence  an  increase  of  the  work  performed.  Later, 
fatigue  set  in  earlier  and  the  contractions  showed  a  much  dim- 
inished amplitude  and  greater  irregularity  than  in  the  normal 
(.Fig.  42.}.  These  observations  agree  with  the  effects  observed 
in  meat-eating  athletes  who  excel  vegetarians  in  a  spurt ' ' , 
z.  <?:,  a  short  contest,  but  who  invariably  fall  out  before  the 
finish  or  come  in  behind  in  cases  of  prolonged  effort. 

THERAPEUTIC  APPLICATION 

The  therapeutic  points  of  practical  importance  which  one 
may  gain  from  the  facts  brought  out  by  the  above  experiments 
are  these:  Hot  applications  are  useful  in  decreasing  the  tonicity 
of  hypertonic  muscles,  lessening  their  irritability  and  reliev- 
ing either  clonic  or  tetanic  spasm.  These  effects  bring 
about  relaxation  and  rest.  The  nervous  system  is  quieted  and 
the  nervous  manifestations  of  extreme  fatigue  disappear  so  that 
ideal  conditions  for  sleep  are  produced.  These  sedative  effects 
are  discussed  further  in  the  part  on  therapeutics.  The  heat 
leaves  no  bad  after-effects.  There  is  no  feeling  of  drowsiness 
or  languor  the  following  forenoon  as  is  so  common  after  sleep 
induced  by  trionol,  veronal,  etc.  Unlike  morphia  or  the  bro- 
mides, heat  does  not  cover  up  or  mask  important  symptoms. 
It  does  not  poison  or  anesthetize  the  nerve  centers  or  endings. 

In  cold  applications  properly  graduated  to  suit  the  needs  of 
various  conditions  we  possess  the  most  useful  muscular  stimu- 
lant and  tonic  known  to  medical  science.  The  stimulating 
effects  of  strychnine  are  not  comparable  with  it.  The  stimula- 
tion produced  by  strychnine  is  not  constant  or  uniform.  Its 
toxic  action  becomes  manifest  in  even  small  doses.  Its  fre- 
quent repetition  soon  wears  out  the  response,  and  depression 
results.  When  frequently  repeated  the  stimulating  stage  is  of 
very  transient  duration  and  later  is  absent  altogether.  It  pro- 
duces a  feeling  of  exhaustion  and  irritability,  rather  than  ex- 
hilaration. "  On  the  whole,  strychnine  must  be  looked  upon  only  as 
a  temporary  remedy.  It  must  be  remembered  that  it  does  not  in 
any  way  permanently  improve  the  condition  of  the  central 


1S8  MUSCULAR  CAPACITY 

nervous  system,  nor  does  it  increase  any  of  the  functions 
except  reflex  irritability.  It  is  doubtful  whether  the  permanent 
maintenance  of  this  artificially  raised  irritability  is  ever  of 
benefit."5 

In  the  case  of  caffeine  the  stimulating-  effects  are  entirely- 
different  from  those  of  cold  and  are  in  no  way  comparable  with 
them.  Caffeine  deadens  the  sense  of  fatigue  and  by  an  irritant 
action  heightens  the  tonicity  of  voluntary  muscle  so  that  its 
response  to  stimulation  is,  for  a  time,  greater  than  normal  and 
it  responds  to  a  feebler  stimulus.  Thus  more  work  is  per- 
formed on  the  mere  stimulation  of  a  cup  of  coffee,  often  when 
the  body  is  already  fatigued  and  should  rest.  Thus  caffeine 
gives  a  false  sense  of  energy  and  as  a  result  the  individual 
neglects  to  take  the  proper  amount  of  food  which  only  is  the 
ultimate  source  of  muscular  energy.  Hence  the  system,  ex- 
hausting its  supply,  draws  on  its  future  resources  and  in  time 
the  constitution  is  undermined. 


5    Sollmann — Pharmacology,  p.  175. 


CHAPTER  XIV 
THE  HEAT  MECHANISM 

ALL  THE  energy  liberated  in  the  body  by  the  decomposition 
and  oxidation  of  food  appears  as  work  or  heat.  Next  to 
the  muscles  in  importance  as  a  source  of  bodily  heat  is  the 
liver.  The  temperature  of  the  blood  in  the  hepatic  vein  is 
higher  than  in  any  other  part  of  the  body.  This  is  doubtless 
because  of  the  magnitude  of  metabolic  changes  which  occur  in 
the  liver. 

On  the  processes  of  metabolism — the  decomposition  and 
oxidation  of  foodstuffs — depend  the  maintenance  of  life.  Hence 
all  living  animals  are  continually  producing  heat  and  imparting 
it  to  the  surrounding  bodies;  and  unless  this  heat  production  is 
more  than  counterbalanced  by  loss  of  heat  in  surface  evapora- 
tion, they  must  have  a  higher  temperature  than  the  surround- 
ing medium,  although  the  difference  may  not  amount  to  more 
than  two  or  three  degrees  in  cases  where  metabolic  processes 
are  going  on  sluggishly. 

'  The  temperature  of  an  animal  is  the  algebraic  sum  of  two 
factors — the  amount  of  heat  produced  and  the  amount  of  heat 
lost  in  a  given  time.  If,  while  the  heat  production  remains 
constant,  the  amount  of  heat  imparted  to  the  surrounding 
medium  be  increased,  the  temperature  will  fall.  If,  on  the 
other  hand,  heat  loss  remaining  constant,  heat  production  be 
raised,  the  temperature  will  rise  in  the  same  proportion.  So 
the  temperature  may  be  regulated  by  alterations  in  the  heat 
production  or  in  the  heat  loss;  and  if  the  temperature  is  to 
remain  constant,  there  must  be  an  accurate  correlation  between 
the  two  processes. 

(139) 


HO  THE  HE  A  T  MECHA  NISM 

REGULATION  OF  HEAT  PRODUCTION 

"  It  has  already  been  mentioned  that,  if  a  frog-  or  other  cold- 
blooded animal  be  exposed  to  a  higher  temperature,  its  internal 
temperature  will  also  rise.  If,  at  the  same  time,  we  measure 
the  respiratory  interchanges  of  the  frog",  we  find  that  at  the 
hig-her  temperature  more  carbon  dioxide  is  evolved  and  more 
oxygen  taken  up,  showing-  that  in  this  case  a  rise  of  tempera- 
ture in  the  surrounding-  medium  causes  a  rise  in  the  tempera- 
ture of  the  frog,  and  at  the  same  time,  increases  the  activity  of 
its  metabolic  chang-es.  Cooling-  has  the  reverse  effect.  If  a 
frog-  be  cooled  to  0°  C.,  the  chemical  changes  in  its  tissues  are 
so  reduced  that  in  may  be  kept  alive  for  some  days  in  an  atmos- 
phere devoid  of  oxyg-en.  The  case  is  quite  otherwise  with 
warm-blooded  animals.  Exposure  of  one  of  them  to  a  cold 
medium  raises  the  amount  of  carbon  dioxide  given  off  and 
oxyg-en  taken  in,  while  the  temperature  of  the  animal  remains 
unaltered.  This  power  of  the  animal  to  react  to  chang-es  in  the 
temperature  of  the  surrounding-  medium  is  dependent  on  the 
integrity  of  the  nervous  system  and  its  connection  with  the 
muscles.  If  a  dog  or  rabbit  be  poisoned  with  curare  (which 
paralyzes  the  muscle  end-plates) ,  or  if  its  spinal  cord  be  divided 
just  below  the  medulla,  its  temperature  sinks  continuously.  It 
is  then  found  that  the  animal  reacts  to  chang-es  in  the  temper- 
ature of  the  surrounding-  medium  precisely  like  a  cold-blooded 
animal — rise  of  the  external  temperature  causing-  rise  of  the 
internal  temperature  and  increased  elimination  of  CO2,  while  a 
fall  of  the  external  temperature  has  the  reverse  effect."  J 

It  has  been  shown  that  metabolism  and  heat  production  are 
proportional  to  the  skin  area  of  the  animal  under  observation. 
The  temperature  nerves  of  the  skin  constitute  the  mechanism 
by  which  thermic  impressions  are  received.  Quantitative  re- 
sults as  reg-ards  heat  production  are,  therefore,  dependent  upon 
the  area  stimulated.  An  animal  whether  of  little  or  much 
weight,  produces  heat  not  according-  to  its  weig-ht  but  according- 
to  the  extent  of  the  skin  surface  exposed  to  the  surrounding- 
medium. 


1     Starling— Physiology.  1907.  pp.  500—503. 


HEAT  LOSS  141 

REGULATION  OF  HEAT  LOSS 

From  the  standpoint  of  hydrotherapy,  however,  of  more  im- 
portance than  the  regulation  of  temperature  by  the  production, 
is  regulation  by  heat  loss.  Heat  is  lost  from  the  body  in  three 
ways.  Only  the  last  two  of  these  are  of  any  practical  impor- 
tance and  the  third  is  of  the  greatest  utility,  for  it  is  largely 
through  this  avenue  that  febrile  temperatures  are  controlled. 
The  three  ways  are  as  follows: — 

/.  By  the  Urine  and  Feces.  About  3  per  cent  of  the  total 
heat  lost  from  the  body  leaves  it  with  the  excretions. 

2.  By  the  Expired  Air.       '  The  inspired  air  is  taken  in  at  the 
temperature  of  the  surrounding  atmosphere,  and  contains  only 
a  small  amount  of  aqueous  vapor.     The    expired    air   has    a 
temperature  of  about  1°  lower  than  the  body  temperature,  and 
is  saturated  with  water  vapor.     Heat  is,  therefore,  lost  in  respi- 
ration in  two  ways:  first,  in  warming  the  inspired  air;  second, 
in  the  evaporation  of  large  quantities  of  water.     These  two 
sources    of  loss  constitute  about  20  per  cent  of  the  total  heat 
loss." 

3.  By  the  Skin.     "  Here  again  the  loss  of  heat  is  affected  in 
two  ways:  first,  by  radiation  and  convection.     By  these  means, 
an  interchange  of  heat  takes  place  between  the  surface  of  the 
body  and  surrounding  objects,  tending  to  cool  the  body  under 
ordinary  circumstances  when  the  external  temperature  is  below 
98.4°  F.,  or  37°  C.,  or  to  warm  the  body  when  the  external 
temperature  is  higher  than  this,  as  during  the  hot  season  in  the 
tropics  or  in  a  Turkish  bath.     The  amount  of  interchange  of 
heat  between  two  bodies  is  directly  proportionate  to  the  differ- 
ence of  temperature  between  them.     Thus,  the  warmer  the  sur- 
face of  the  body  in  comparison  with  that  of  surrounding  objects , 
the  greater  will  be  the  amount  of  heat  interchange  which  in 
this  case  implies  a  loss  of  heat  to  the  body.     Since  very  little 
heat  is  generated  in  the  skin  itself,  its  temperature  is  intim- 
ately dependent  on  the  amount  of  blood  flowing  through  it, 
and  this  in  its  turn  on  the  condition  of  the  blood-vessels  of  the 
skin.     When  these  are  dilated,  there  is  a  constant  supply  of 
warm  blood  from  the  deeper  parts  of  the  body  to  the  skin ,  which 


J4f  THE  HEAT  MECHANISM 

therefore,  is  kept  warm  and  feels  warm,  both  subjectively  and 
objectively.  Hence  dilatation  of  the  blood-vessels  of  the  skin 
under  normal  circumstances  brings  about  increased  loss  of  heat. 
If,  on  the  other  hand,  the  vessels  are  constricted,  the  small 
amount  of  blood  supplied  to  the  skin  rapidly  becomes  cooled 
and  the  skin  is  also  cool,  and  the  loss  of  heat  small. 

"Second,  by  the  evaporation  of  the  sweat.  In  the  conver- 
sion of  water  into  watery  vapor,  a  large  amount  of  heat  becomes 
latent.  This  principle  is  made  use  of  in  making-  ice,  or  in  cool- 
ing a  bottle  of  water  by  surrounding  it  with  damp  cloths  which 
are  exposed  to  a  draught  of  air  to  facilitate  evaporation.  If  the 
secretion  of  sweat  is  small ,  it  evaporates  as  it  is  secreted  and 
the  skin  remains  dry.  This  is  spoken  of  as  insensible  perspira- 
tion. If  the  secretion  be  very  copious,  it  may  be  formed 
faster  than  it  can  evaporate,  and  appears  on  the  skin  as  drops 
of  sensible  perspiration.  The  formation  of  sensible  perspira- 
tion depends  then  on  two  factors — the  amount  of  sweat  secreted 
and  the  rapidity  of  evaporation,  which  latter  again  is  dependent 
on  the  amount  of  saturation  of  the  surrounding  atmosphere 
with  watery  vapor. 

'  The  loss  of  heat  by  the  skin  amounts  to  about  77  per  cent 
of  the  total  heat  loss,  and  is,  therefore,  the  most  important  of 
all  the  channels  for  the  discharge  of  heat.  The  regulation  of 
the  total  heat  loss  is  also  effected  chiefly  by  changes  in  the  loss 
through  the  skin.  The  nervous  channels  by  which  this  is  car- 
ried out  are  the  vasomotor  and  the  sweat  nerves.  If  the  ex- 
ternal temperature  be  below  that  of  the  body,  the  loss  by  radia- 
tion and  convection  may  be  sufficient  to  get  rid  of  the  excess  of 
heat  produced.  If,  however,  the  external  temperature  be 
higher  than  that  of  the  body,  radiation  and  convection  will 
serve  only  to  warm  the  body  still  further,  and  the  sole  loss  of 
heat  that  can  be  affected  is  by  the  evaporation  of  sweat,  which 
is  accordingly,  under  such  circumstances,  secreted  in  large 
quantities  {Fig.  43.). 

Often,  especially  after  severe  muscular  exercise,  radiation 
and  convection  are  not  sufficient  to  carry  off  the  excess  of  heat 
produced,  and  hence  there  is  a  copious  secretion  of  sweat  as 
well,  even  though  the  external  temperature  may  be  cool."  2 

2    Starling— Physiology,  pp.  504—506. 


HEAT  LOSS 


143 


The  relative  values  of  the  different  means  of  heat  loss  are 
estimated  by  Vierordt  as  follows: — 

1.  By  urine  and  feces  1.8  per  cent 

2.  By  expired  air:  warming-  of  air  -    3.5    ' 

Vaporization  of  water  from  the  lungs  7.2 

3.  By  evaporation  from  the  skin                  -  14.5 

4.  By  radiation  and  conduction  from  skin  73.0 


H,«ot  Lou  i  ix  Calories  -per  Kxloqram 


Fig.  43.    Rubner's  chart  showing-  the  manner  of  heat  loss  at 

different  room  temperatures  in  the  dog.     ,  heat  loss  in 

calories  through   evaporation  of  water;  ,  heat  loss  in 

calories  through  radiation  and  convection. 

' '  So  perfect  is  the  adaptation  of  the  heat  loss  to  the  heat  pro- 
duction, that  a  man  may  travel  from  the  poles  to  the  equator, 
may  eat  or  fast,  take  exercise  or  rest,  without  causing  any 
lasting  alteration  in  his  temperature  of  1°  C.,  though  violent 
exercise  may  induce  in  many  individuals  a  temporary  rise  of 
temperature  of  2°  C."-3 

3    Starling — Physiology,  p.  506. 


m  THE  HEAT  MECHANISM 

' '  We  may  at  present  adopt  the  conservative  view  that  heat 
production  and  heat  dissipation  in  the  body  are  controlled  not 
by  a  special  heat-regulating  apparatus,  composed  of  heat  centers 
and  heat  nerves,  but  by  the  coordinated  activity  of  a  number  of 
different  centers  in  addition  to  the  voluntary  means  already 
specified.  The  unconscious  regulation  of  the  body  temper- 
ature is  effected  chiefly  through  the  following: — ' ' 

Heat  Dissipation. 

1.  The  sweat  centers  and  sweat  nerves. 

2.  The  vasoconstrictor  centers  and  their  nerve  fibers  to  the 
skin. 

3.  The  respiratory  center. 
Heat  Production. 

1 .  The  motor  nerve  centers  and  the  motor  nerve  fibers  to  the 
skeletal  muscles. 

2.  The  quantity  and  character  of  the  food. 

3.  Secretory  and  other  glandular  nerves. 

The  principal  parts  of  this  heat-regulating  mechanism  and 
their  relation  to  each  other  are  well  shown  in  the  accompanying 
diagram  (Fig.  44.). 

EXPERIMENTS  IN  HEAT  PRODUCTION 
AND  ELIMINATION 

In  the  clinical  study  of  the  heat  mechanism  it  is  necessary  to 
understand  something  of  the  means  employed  in  such  study. 
To  ascertain  the  heat  output  of  any  organism  some  form  of 
calorimeter  is  used.  The  most  accurate  calorimeters  are  those 
that  utilize  water  for  the  absorption  of  the  heat  communicated 
from  the  body.  From  the  total  volume  of  the  water  and  the 
change  in  its  temperature  it  is  an  easy  matter  to  figure  the 
number  of  calories  absorbed  by  it,  and  consequently  the  amount 
of  heat  given  off  from  the  body  under  experiment  in  a  given 
length  of  time.  This  of  course  is  the  quantity  of  heat  elimin- 
ated. If  the  temperature  of  the  organism  remains  constant 
during  the  experiment,  then  its  heat  production  is  equal  to  its 
heat  elimination.  If  the  temperature  rises  or  falls,  the  increase 
or  decrease  of  heat  production  above  or  below  the  heat  elimina- 
tion can  be  estimated  from  the  weight  of  the  body  and  change 
in  the  temperature. 

4    Modified  from  Howell— Physiology.  1908.  p.  866. 


CALORIMETERS  Itf 

The  construction  of  the  calorimeter  for  animal  experiments 
can  be  readily  grasped  from  a  study  of  Fig.  45.  For  rough 
clinical  work  a  bath  tub  of  water  may  be  utilized.  The  tem- 
perature of  the  water  serves  to  make  the  thermic  application 
with  which  it  is  desired  to  experiment  and  its  volume,  together 
with  the  changes  in  its  temperature  serve  as  the  basis  for  figur- 
ing" the  heat  elimination  in  calories.  It  has  the  disadvantage 
of  being-  unsuitable  for  estimating-  the  after  results  of  thermic 


Fig.  44.  Diagram  showing  heat-regulating  mechanism. 
H — heat-regulating  center,  F — center  for  heat  formation. 
D — center  for  heat  dissipation,  V — vasomotor  center,  T — 
thermogenic  tissues,  S — center  for  sweat  glands,  C — 
capillary  blood-vessels  of  skin,  G — sweat  gland.  (Wood.) 

applications.  For  after  results  relative  values  may  be  obtained 
by  the  d' Arson  val  calorimeter.  This  instrument  is  a  large 
upright  cylinder  of  heavy  pasteboard  or  other  good  non-con- 
ductor. The  upper  end  is  closed  except  for  an  opening  in  which 
is  fitted  an  anemometer  and  the  lower  end  also  except  for  small 
openings  to  admit  air.  The  subject  of  the  experiment  stands 

in  this  cylinder,  the  heat  of  the  body  causing  a  movement  of 
10 


J46  THE  HE  A  T  MECHA  NISM 

air  which  is  registered  by  the  anemometer.  The  results  are  of 
course  only  relative  but  are  of  value  in  determining  an  increase 
or  decrease  of  heat  elimination. 

For  our  purpose  no  time  need  be  spent  on  experimental 
proof  of  the  effects  of  muscular,  glandular,  and  pther  vital 
activities  on  heat  production  and  elimination.  We  wish,  how- 
ever, to  quote  more  or  less  at  length  the  experimental  basis  of 


en  IENT 


Fig.  45.    Reicherfs  water  calorimeter. 

the  physiologic  effects  of  hydriatic  applications  upon  heat  pro- 
duction and  heat  loss.  Kellogg's  experiments5  along  this  line 
.are  very  practical  since  the  tests  were  made  after  applications 
of  the  intensity  and  duration  actually  employed  in  practice. 

\\  .  was  .yiven  a  cold  percussion  douche  for  thirty  seconds. 
The  change  in  rectal  temperature  immediately  after  revealed 
an  increase  of  nearly  ninety  heat  units  and  this  in  spite  of  the 
increased  heat  elimination  resulting  from  the  reaction.  Another 


CLINICAL  EXPERIMENTS  147 

experiment  upon  a  subject  A.  revealed  the  fact  that  while  quiet 
immersion  in  a  bath  at  82°  F.  for  five  minutes  absorbed  heat 
from  the  body,  it  did  not  cause  any  material  increase  in  heat 
production  above  the  normal  amount  or  rate.  When  the  same 
subject  was  placed  in  a  bath  at  77°  F.  and  rubbed  constantly 
during-  the  five  minutes,  heat  loss  was  increased  three  times 
and  heat  production  six  times  the  normal  amount.  P.  was 
given  a  short  hot  spray  at  106°  F.  By  means  of  a  bath  tub 
calorimeter  it  was  estimated  that  heat  production  had  been  de- 
creased 22.7  per  cent.  By  means  of  a  d'Arsonval  calorimeter 
it  was  shown  that  oiling  the  skin  decreased  heat  elimination  45 
per  cent. 

A  series  of  four  tests  with  the  d'Arsonval  calorimeter  were 
made  upon  W.  In  a  room  temperature  of  70°  F.,  when  placed 
in  the  calorimeter,  the  elimination  of  heat  from  his  body  pro- 
duced, as  shown  by  the  anemometer,  an  air  movement  at  the 
rate  of  123  feet  per  minute.  After  an  electric  light  bath  suffi- 
cient to  redden  the  skin  without  sensible  perspiration  the  air 
movement  increased  to  140  feet  per  minute.  After  an  electric 
lig-ht  bath  to  profuse  perspiration  the  rate  of  air  movement  was 
170  feet  per  minute.  After  a  cold  percussion  douche  at  60°  F. 
for  two  minutes  the  air  movement  was  70  feet  per  minute. 
In  ten  minutes,  when  reaction  had  taken  place,  it  was  110  feet 
per  minute. 

By  means  of  a  bath  tub  calorimeter  it  was  ascertained  that  a 
certain  subject  when  immersed  in  water  at  70°  F.  imparted  heat 
to  the  water  to  the  extent  of  raising  its  temperature  0.72°  in 
five  minutes.  When  friction  was  applied  the  temperature  of 
the  water  rose  at  the  rate  of  1.08°  F.  in  five  minutes,  or  an 
increase  of  50  per  cent  in  heat  elimination. 

The  giving  of  copious  enemata  at  70°  F.  at  intervals  of 
twenty-five  minutes  for  an  hour  and  a  half  to  a  subject  S. 
reduced  the  mouth  temperature  from  98°  to  96.9°  F.,  and  the 
rectal  temperature  from  100°  to  95.2°  F. 

The  drinking  of  seven  glasses  of  lemonade  at  58°  F.  in  the 
case  of  M.  produced  in  twenty  minutes  the  following  changes: — 

Temp.  By  Axilla  By  Mouth  Per  Rectum  On  Epigastrium 

Before          97.7°  98.7°  99.2°  97° 

After  96.1°  98.0°  98.0°  92° 


Temperature 

Increased 

Increase  of 

of  Bath 

Heat  Production 

Metabolism  in 

Grams  of  Fat 

95°  F. 

7  calories 

0.7  grams 

86°  F. 

77 

7.0     " 

77°  F. 

167      " 

18.0 

68°  F. 

297 

31.0 

59°  F. 

407 

43.0 

14S  THE  HEAT  MECHANISM 

It  has  already  been  mentioned  that  for  every  fall  of  1°  C.  in 
the  surrounding  temperature  there  is  an  increase  of  metabol- 
ism amounting  to  2  or  3  per  cent.  Rubner,  experimenting 
with  a  bath  of  one  hour's  duration,  obtained  the  following 
results  in  the  case  of  a  man  weighing  sixty  kilograms  and  in 
whom  there  was  a  normal  heat  production  of  91  calories  per 
hour. 

Effects  of  Bathing  on  Heat  Production 

Total  Effects  During 
and  af.er  Bath 

0.7  grams 
9.0     " 
22.0     " 
37.0 
52.0 

In  regard  to  the  heat  loss  it  is  estimated  that  in  a  bath  at 
86°  F.  the  heat  loss  is  doubled;  in  a  bath  at  77°  F.  it  is  tripled; 
and  at  68°  F.  it  reaches  five  times  the  normal.  It  is  interesting 
to  note  that  more  than  half,  and  sometimes  as  high  as  two- 
thirds  of  the  total  heat  loss  in  a  cold  bath  occurs  during  about 
the  first  third  of  the  treatment.  In  a  cold  bath  at  80°  F.  of 
fifteen  minutes  duration  and  with  a  total  heat  loss  of  75  cal- 
ories, 43  calories  of  this  heat  loss  occurred  during  the  first  five 
minutes.  In  another  case  with  a  cold  bath  at  63°  F.  of  two 
and  one-half  minutes  duration  and  a  total  heat  loss  of  65  cal- 
ories, nearly  44  calories  of  this  were  lost  during  the  first 
minute.  Because  of  these  facts  short  cold  baths  are,  propor- 
tionately to  their  duration,  more  effective  in  heat  elimination 
than  long  cold  baths. 

The  reason  for  the  greater  heat  loss  early  in  the  course  of  a 
cold  bath  is  doubtless  due  to  the  fact  that  the  body  is  unpre- 
pared to  resist  the  abstraction  of  heat,  consequently  the  high 
heat  loss.  But  very  soon  the  heat-regulating  centers  set  in 
motion  vascular  and  other  changes  which  are  intended  to  econo- 
mize the  body  heat  as  far  as  possible,  i.  <?.,  resist  heat  loss  as 
well  as  provide  for  increased  heat  production.  The  body  tends 
to  resist  the  abstraction  of  heat  brought  about  by  contact  with 
cold  water  by  making  more  unfavorable  the  conditions  for  heat 
elimination. 


CLINICAL  EXPERIMENTS 


149 


The  activity  of  the  surface  circulation  being  the  essential 
factor  in  the  loss  of  heat  during  a  cold  bath,  it  follows,  there- 
fore, that  whatever  increases  the  amount  of  blood  in  the  skin 
and  the  rapidity  of  the  circulation  in  the  skin  will  markedly 
increase  heat  loss  during  a  cold  bath.  This  is  one  of  the  chief 
reasons  for  the  use  of  short  hot  applications  preparatory  to  the 
use  of  the  cold  bath. 


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Figf.  46.     Chart  showing  heat  elimination  by  the  skin  as  affected  by 
various  physical  measures,  thermic  applications,  etc. 


The  following  are  some  of  the  results  claimed  by  Otto  Pos- 
pischl  as  a  result  of  his  work  as  assistant  to  Professor  Winter- 
nitz.  (Fig.  46. Y 

1.  Displacing  the  blood  and  arresting  the  circulation  in  a 
part  of  the  body  lessens  heat  loss  as  much  as  70.6  per  cent. 


5     Buxbaum— Lehrbuch  der  Hydrotherapie,  II  Auflage,  p.  48. 


150  THE  HEAT  MECHANISM 

2.  Hindering  the  circulation  through  the  production  of  pas- 
sive hypcremia  lessens  heat  loss  as  much  as  46.2  per  cent. 

3.  Mechanical  irritation  may  occasion  an  increase  of  heat  loss 
up  to  95  per  cent. 

4.  Weak  chemical  irritation  produces  an  increase  of  heat  loss 
to  40  per  cent,  strong  irritation  on  the  other  hand  a  decrease  up 
to  8  per  cent. 

5.  Thermic  influences  which  cause  goose  flesh  decrease  heat 
loss  as  much  as  44.5  per  cent. 

6.  A  hot  rain  bath  may  through  the  production  of  goose  flesh 
cause  a  lessening  of  heat  loss  up  to  38.7  per  cent. 

7.  Partial  cold  wet  friction  may  raise  the  heat  loss  as  much 
as  80  per  cent. 

8.  Cold  rain  baths  and  rest  following  produce  after  a  transi- 
tory decrease  of  heat  loss  an  increase  up  to  23  per  cent. 

9.  Cold  rain  baths  with  exercise  following  raise  heat  loss  as 
much  as  66.6  per  cent. 

10.  Warm  rain  baths  with  cold  fan  douche  and  rest  following 
raise  the  heat  loss  up  to  16  per  cent. 

11.  In  two  illnesses  with  increasing  fever  the  heat  loss  was 
decreased  as  much  as  25.4  per  cent. 

SUMMARY 
Heat  Production  (Thermogenesis) 

The  following  are  some  of  the  conditions  and  measures  that 
increase  heat  production: — 

Vital  activities  such  as, — 

1.  Glandular  activity. 

2.  Muscular  activity. 

3.  Digestive  activity. 

4.  Mental  activity. 

External  conditions, — 

5.  Reaction  to  cold  applications  (either  long  or  short). 

6.  Friction. 

7.  Low  atmospheric  temperatures. 

8.  High  atmospheric  temperatures. 


SUMMARY  151 

The  following-  conditions  and  measures  decrease  heat  produc- 
tion:— 

1.  Fastingf. 

2.  Sleep  and  rest. 

3.  Reaction  to  short  hot  applications. 

Heat  Elimination  (Thermolysis) 

The  following:  conditions  increase  heat  elimination;  the  agents 
or  means  which  produce  these  conditions  are  listed  as  subordin- 
ates. 

1.  Dilated  surface  vessels  and  rapid  circulation, — 

(a)  Heat. 

(b)  Short  cold  (reaction). 

(c)  Friction. 

(d)  Exercise. 

(e)  Weak  chemical  irritants. 

2.  Increased  perspiration  (by  evaporation  of  water),— 

(a)  Heat. 

(b)  Friction. 

(c)  Exercise. 

(d)  Water-drinking. 

3.  Increased  rate  of  respiration. 

More  or  less  prolonged  applications  of  cold,  whether  cold 
water  or  cold  air,  abstract  heat  from  the  body  by  conduction; 
but  they  tend  to  make  the  body  resist  this  effect;  that  is,  it 
attempts  to  counteract  heat  elimination. 

The  following  measures,  while  they  cause  the  body  to  make 
attempts  at  decreased  heat  elimination,  do,  by  contact,  abstract 
heat: — 

1.  Cold  baths. 

2.  Cold  enemata. 

3.  Cold  water-drinking. 

4.  Breathing  cold  air. 

Conditions  that  decrease  heat  elimination: — 

1.  Contracted  surface  vessels  and  slowed  circulation  (as  in 
goose  flesh). 

2.  Decrease  of  perspiration  (lessened  evaporation). 


15i  THE  HEAT  MECHANISM 

3.  Decrease  in  volume  of  tidal  air,  slow  or  shallow  respira- 
tion. 

4.  Very  high  atmospheric  temperatures. 

5.  Oiling:  of  the  skin. 

There  are  two  local  applications  of  cold  whose  chief  effect 
upon  the  body  temperature  is  not  by  the  abstraction  of  heat. 
These  are  the  ice  cap  applied  to  the  head  and  the  ice  bag- 
applied  over  the  heart.  Their  action  is  reflex.  The  former 
influences  heat  production  through  its  reflex  effect  upon  the 
thermogenic  centers  of  the  brain.  The  latter  reflexly  slows  the 
heart  beat  and  thereby  the  general  circulation,  which  in  turn 
decreases  heat  production.  Of  course,  as  previously  stated, 
these  effects  are  very  slight  in  health  but  of  inestimable  value 
in  febrile  diseases. 

Heat  Regulation  (Thermotaxis) 

The  normal  temperature  of  the  body  is  maintained  by  the 
nicety  of  the  balance  between  heat  production  and  heat  elimin- 
ation. Increased  heat  production  does  not  necessarily  mean  a 
rise  of  body  temperature,  since  under  normal  conditions  the 
heat  is  dissipated  as  rapidly  as  produced.  The  natural  condi- 
tions that  tend  to  increase  heat  production  usually  stimulate  the 
elimination  of  heat  as  well,  and  so  a  balance  is  maintained. 
For  example,  the  body  is  exposed  to  a  draft  of  cold  air.  The 
skin  assumes  a  goose  flesh  appearance  by  contraction  of  the 
involuntary  muscles;  it  is. pale  and  contains  less  blood.  While 
the  cold  air  abstracts  or  conducts  heat  from  the  body,  this  less- 
ened circulation  in  the  skin  decreases  the  amount  of  heat  lost 
from  the  surface.  The  perspiratory  glands  are  less  active,  and 
the  consequent  lessened  evaporation  of  water  from  the  skin  also 
decreases  the  amount  of  heat  eliminated.  At  the  same  time 
the  sensation  of  cold  influences  the  thermogenic  centers,  and 
they  cause  the  tissues  to  produce  more  heat.  Even  the  shiver- 
ing which  follows  the  exposure  to  cold,  being  muscular  action, 
is  one  method  of  producing  heat. 

Thus  the  temperature  of  the  body  is  maintained  at  a  con- 
stant point  rather  than  lowered  by  the  cold  atmosphere.  The 
converse  is  true  of  a  short  moderately  warm  bath.  This  would 


THERMOTAXIS  153 

communicate  heat  to  the  body,  and  so  tend  to  raise  the  tem- 
perature; but  the  body  reacts  in  such  a  way  as  to  preserve  the 
balance.  The  skin  is  relaxed,  the  blood-vessels  dilated  and  the 
perspiration  increased,  so  that  more  heat  is  lost  by  dissipation 
from  the  surface.  At  the  same  time  this  relaxing  effect  causes 
loss  of  tone  in  the  tissues  generally,  and  so  less  heat  is  produced. 
These  results  are  due  to  the  control  exercised  by  the  heat-regu- 
lating centers  before  mentioned. 

It  must  not  be  supposed,  however,  that  heat  always  decreases 
heat  production.  Very  high  temperatures  markedly  increase 
heat  production,  so  much  so  that  fatal  poisoning  may  occur  in 
such  conditions  as  heatstroke.  Serious  cases  never  wholly 
recover  from  the  effects  of  the  high  external  temperature  and 
the  internal  heat  produced  by  it.  They  are  ever  after  extremely 
susceptible  to  even  the  moderate  heat  of  tropical  climates  or 
direct  sunlight. 

While  an  agent  may  increase  both  heat  production  and  elim- 
ination at  the  same  time,  one  is  usually  increased  to  a  greater 
extent  than  the  other.  For  example,  a  cold  mitten  friction  at 
first  abstracts  heat  from  the  body,  but  the  reaction  causes 
increased  heat  production,  as  shown  by  the  "warming  effect." 
The  increased  circulation  of  the  skin,  which  is  part  of  the 
reaction,  causes  more  heat  to  be  lost.  The  total  effect,  how- 
ever, is  an  increase  of  heat  in  the  body,  because  heat  produc- 
tion is  stimulated  more  than  heat  elimination. 

As  we  have  seen,  thermic  applications  produce  decided 
changes  in  heat  production  and  elimination.  However,  these 
changes  do  not,  in  health,  produce  wide  alterations  in  the  body 
temperature.  On  the  contrary,  the  same  influences  applied  in 
febrile  conditions  produce  decided  alterations. 

From  the  preceding  experiments  it  will  be  seen  that  water  at 
the  varying  temperatures  and  in  the  different  ways  in  which  it 
may  be  applied  to  the  body,  is  capable  of  any  and  all  possible 
variations  and  degrees  of  effect  upon  the  heat  mechanism .  No 
possible  alteration  of  heat  production  or  elimination  can  be  con- 
ceived of  that  water  is  not  capable  of  producing.  It  is  this 
versatility  of  application  and  effect  that  makes  hot  and  cold 
water  of  so  much  service  in  fever  and  disturbances  of  the  heat 
mechanism. 


154  THE  HEAT  MECHANISM 

On  the  contrary,  drug-  action  is  particularly  monotonous,  and 
ideal  combinations  impossible  to  make.  If  they  seem  to  act  in 
a  rational  manner  upon  one  part  of  the  mechanism,  it  -will  be 
found  that  they  have  an  adverse  action  upon  another  part. 
And  usually  this  adverse  action  more  than  outweighs  any  good 
which  may  be  accomplished.  There  are  no  drug's  which  in- 
crease heat  production  by  stimulating  oxidation  which  are  at 
all  safe  to  use.  Those  drugs  such  as  acetanilid  and  quinine, 
which  decrease  heat  production,  do  so  by  a  toxic  action  upon 
the  thermogenic  centers  and  tissues,  so  that  there  is  an  increase 
of  the  toxic  products  of  metabolism  rather  than  a  decrease.  On 
the  other  hand  the  drugs,  such  as  alcohol  and  aconite  which 
bring  about  greater  heat  elimination  by  dilating  the  surface 
vessels,  accomplish  this  by  paralyzing  the  *vasomotors,  a  result 
which  is  not  only  undesirable  in  fevers  but  often  positively  dan- 
gerous, as  will  be  shown  under  the  subject  of  fever  and  anti- 
pyretic effects. 


PART  II 

THERAPEUTICS 


CHAPTER   XV 

THE  REALM  AND  LIMITATIONS  OF 
PHYSIOLOGIC  THERAPY 

THERAPEUTICS  is  the  science  and  art  of  healing-.  Dis- 
ease is  an  abnormal  state  of  the  body  manifest  in  a  morbid 
condition  of  structure  or  function.  The  departure  from  the 
normal  nearly  always  begins  in  some  mild  way.  Even  in  acute 
diseases  the  predisposition  is  laid  in  previous  unhygienic  habits 
or  surrounding's.  There  are  two  general  types  of  disease  us- 
ually recog-nized,  viz.,  the  functional  and  the  organic.  In  the 
former  the  actual  structure  of  the  diseased  organ  or  part  has 
not  greatly  deviated  from  the  normal.  The  condition  is  mani- 
fest in  a  derangement  of  the  function  of  the  part.  However, 
even  in  many  so-called  functional  diseases  it  is  possible,  by 
careful  microscopic  examination,  to  detect  more  or  less  of 
pathologic  change.  But  even  in  this  case  the  alteration  in 
structure  has  not  gone  on  to  such  an  extent  as  to  preclude  the 
possibility  of  a  restoration  to  normal  more  or  less  complete. 

In  the  case  of  organic  disease  such  gross  structural  changes 
have  been  produced  as  to  be  readily  detected,  and  of  such  a 
character  as  to  preclude  the  possibility  of  a  return  to  the  normal. 
In  this  case  physiologic  therapy  can  accomplish  only  aleviation 
of  the  symptoms  and  such  building  up  of  the  general  vitality 
and  resistance  of  the  patient  as  to  more  or  less  counterbalance 
the  effects  of  the  structural  lesion.  In  many  cases  where  no 
indispensable  part  is  involved  radical  means  may  be  used,  such 

(155) 


156  REALM  OF  PHYSIOLOGIC  THERAPY 

as  the  removal  of  a  malignant  neoplasm,  or  some  operation 
may  de  done  to  overbalance  or  palliate  the  results  of  the  dis- 
ease, as  in  the  case  of  Talma's  operation  for  hepatic  cirrhosis 
or  Edobohl's  operation  for  renal  insufficiency.  Purely  func- 
tional diseases  are,  however,  nearly  always  best  treated  by 
physiologic  means. 

In  the  course  of  many  diseases  a  point  is  reached  beyond 
which  a  return  to  the  normal  is  impossible  without  the  inter- 
vention of  some  radical  procedure.  This  is  especially  the  case 
in  inflammations.  In  certain  grades,  stages,  and  types  of 
inflammation  it  is  entirely  possible,  by  natural  means,  to  aid  or 
affect  the  return  to  normal  structure  without  the  intervention 
of  radical  measures.  This  is  true  of  such  an  inflammation  as 
dry  or  serous  pleurisy,  pneumonia,  or  a  simple  surface  infec- 
tion, but  where  these  inflammations  have  gx>ne  on  to  the 
formation  of  a  suppurative  focus  or  an  abscess,  physiologic 
means  alone  are  unable  to  accomplish  the  full  return  to  the 
normal  condition.  True,  in  time,  the  abscess  mig-ht  work  its 
way  to  the  surface,  and  so  evacuate,  but  in  most  cases  it  is  a 
long,  tedious  process  and  the  patient  is  very  much  reduced  in 
vitality  by  such  delay,  which  delay  may  prove  fatal  from  the 
absorption  of  toxic  products.  It  is  necessary,  by  some  radical 
means,  to  accomplish  the  speedy  evacuation  of  the  pus  and  free 
drainage  of  the  abscess  cavity.  The  old  dictum,  ubi  pus,  ibi 
evacua,  is  just  as  true  now  as  when  it  was  first  enunciated. 
Translated  into  terms  of  activity,  it  means,  where  there  is  pus, 
provide  an  outlet.  It  is  necessary  that  evacuation  be  provided 
for.  This,  nature  itself  seeks  to  accomplish;  but  unaided,  its 
attempts  are  accompanied  by  great  destruction  of  tissue  and 
much  delay.  By  vigorous  treatment,  systematically  applied, 
it  is  often  possible  to  obviate  the  necessity  for  radical  interfer- 
ence. But  when  the  stage  of  suppuration  has  been  reached  or 
is.  imminent,  surgical  intervention  is  just  as  much  an  assistant 
to  nature  as  physiologic  means  and  therefore  just  as  rational. 

The  same  principles  apply  to  the  use  of  vaccines  and  anti- 
toxines.  If  the  body  has  sufficient  reserve  power  and  the  in- 
fection does  not  progress  too  rapidly,  the  system  may  provide 
adequate  means  of  cure.  Yet  the  course  of  certain  infections 


RADICAL  THERAPY  157 

teaches  us  that  such  circumstances  can  not  always  be  relied 
upon.  Where  available  and  of  demonstrated  value,  no  one 
would  think  of  omiting  the  use  of  serum  therapy.  When  it  is 
used,  physical  means  should  not  be  left  out  simply  because  other 
procedures  are  more  essential  in  a  given  case.  All  measures  of 
value  should  be  used  in  order  to  still  further  assist  the  body  in 
combating"  the  infection. 

We  may  then,  in  general,  say  that  where  physiologic  means 
are  unable  to  aid  the  organism  in  reestablishing  the  normal 
structure  and  function,  radical  interference  is  necessary.  This 
division  line  can  best  be  determined  by  careful  consideration  of 
the  usual  trend  of  the  particular  disease  in  question.  Experi- 
ence has  shown  that  a  certain  type  of  inflammation  in  one  organ 
or  location  may  early  tend  to  a  serious  issue,  such  as  abscess 
or  gangrene,  while  in  another  organ  or  location,  there  is  less 
immediate  danger,  the  inflammation  tending  to  become  chronic. 
For  example,  we  may  cite  the  case  of  appendicitis  on  the  one 
hand  and  of  salpingitis  on  the  other.  In  both  cases,  physiologic 
means  may  accomplish  a  return  to  the  normal,  but  in  the  case 
of  appendicitis,  this  return  is  not  to  be  relied  upon  for  per- 
manent cure.  The  tendency  is  to  recurrence  and  even,  in  a 
single  attack,  to  perforation  and  peritonitis;  while  with  the 
pelvic  inflammation,  physiologic  means  produce  a  safe  issue 
which  can  better  be  relied  upon  for  permanency;  i.  e.,  if  taken 
early,  there  is  little,  or  at  least  less,  tendency  to  rupture  and 
abscess  formation.  Even  in  the  case  of  formation  of  pus  in  the 
tube,  it  is  best  to  delay  surgical  interference  until  the  acute 
inflammation  has  subsided  and,  if  possible,  the  temperature  has 
returned  to  normal.  At  best,  it  is  dangerous  and  conducive 
to  spread  of  infection  if  salpingectomy  be  done  during  the 
continuance  of  the  acute  inflammation. 

It  is  quite  otherwise  with  appendicitis.  Not  only  does  opera- 
tion in  the  acute  stage  give  good  results,  but  because  of  the 
inability  to  determine  the  immediate  issue,  it  is  imperative  to 
interfere  as  soon  as  possible.  True,  a  patient  may  go  through 
a  number  of  acute  attacks,  all  of  which  subside  without  serious 
complications,  but  this  can  not  be  relied  upon  to  continue.  In 
each  succeeding  attack  there  is  greater  liability  to  perforation. 


158 

Considering-  all,  we  may,  then,  draw  the  conclusion  that 
rational  therapy  is  based  upon  three  things, — experimsnt,  ex- 
perience and  judgment, — the  latter  for  the  purpose  of  apply- 
ing to  the  individual  case  the  general  laws  and  deductions 
relative  to  that  condition.  It  requires  an  extreme  nicety  and 
perfect  balance  of  judgment  to  determine  whether  a  given 
border  line  case  should  be  treated  by  physiologic  or  radical 
therapy.  This  faculty  has  been  termed  "  surgical  judgment." 
But  its  application  requires  more  than  a  knowledge  of  operative 
technique.  The  surgeon  who  is  pre-eminently  a  physician  and 
whose  armementarium  is  well  stocked  with  physiologic  means, 
will  meet  with  the  best  success.  Let  not  the  surgeon  be  over 
enthusiastic  about  operative  treatment  nor  the  physician  so 
confident  of  natural  means  as  to  procrastinate  when  prompt 
surgical  interference  offers  the  best  hope  of  speedy  and  per- 
manent recovery. 

In  some  organic  diseases  the  principle  involved  in  physiologic 
therapy  is  that  of  calling  into  requisition  certain  vicarious 
functions,  of  stimulating  structures  which  may  relieve  the 
diseased  tissue  or  organ  of  part  of  its  work.  This  is  notably 
the  case  in  valvular  heart  lesions  and  in  the  various  forms  of 
Bright' s  disease.  In  valvular  heart  disease  the  blood-vessels 
may  be  made  to  assume  much  of  the  circulatory  function  and 
so  relieve  the  central  heart  to  that  extent.  To  a  limited  degree 
the  sweat  glands  may  in  Bright' s  disease  be  made  to  supple- 
ment the  work  of  the  kidneys. 

We  have  already  learned  that  the  basic  principle  of  physio- 
logic therapy  lies  in  bringing  into  requisition  the  natural  forces 
of  the  organism,  of  toning  up  and  stimulating  its  natural  powers 
of  defense,  making  the  body  itself  take  part  in  its  own  healing. 
To  do  this  most  effectively  the  physician  must  become  thor- 
oughly conversant  with  normal  and  abnormal  physiology  and 
spend  his  best  efforts  in  studying  the  methods  naturally  pur- 
sued by  the  organism  in  defending  itself  against  a  given  cause 
or  pathogenic  agent.  These  natural  methods  of  defense  we 
shall  endeavor  to  point  out  in  connection  with  the  treatment  of 
the  various  diseases  which  are  amenable  to  physiologic  therapy. 


PRINCIPLES  OF  THERAPY  159 

BASIC  PRINCIPLES  OF  THERAPY 

The  philosophy  of  the  practice  of  therapeutics  is  summed  up 
in  three  things.  The  proper  application  of  these  may  be  con- 
sidered rational  medicine. 

First,  removal  of  the  cause. 

Second,  treatment  of  the  existing  conditions. 

Third,  relief  of  such  symptoms  as,  by  their  severity,  in  turn  be- 
come causes. 

After  removal  of  the  cause  many  functional  diseases  right 
themselves  (sublata  causa,  tollitur  effectusY  without  further  treat- 
ment, since  perverted  habits  of  function  have  not  become  fixed. 
In  the  large  majority  of  cases  in  addition  to  the  removal  of  the 
cause,  it  is  necessary  to  direct  attention  to  the  existing  perver- 
sions of  function  and  structure.  Usually,  the  measures  found 
most  successful  in  the  treatment  of  a  disease  meet  all  three  of 
these  indications.  It  is,  therefore,  seldom  necessary  to  direct 
treatment  to  each  separately.  For  example,  in  typhoid  fever 
the  cold  bath  increases  phagocytosis,  thus  combating  the  cause 
— infection;  it  relieves  internal  congestion;  increases  the  oxida- 
tion and  elimination  of  toxines;  it  relieves  the  nervous  symp- 
toms; sustains  the  heart  and  circulation;  and  lessens  the  fever. 
A  single  procedure  meets  all  three  indications  and  thus  proves 
itself  the  summum  bonum  of  therapeutics  in  the  treatment  of 
this  disease.  The  same  is  true  of  many  other  diseases. 


1    When  the  cause  is  removed,  the  effect  disappears. 


CHAPTER   XVI 

FEVER  AND  ANTIPYRETIC  EFFECTS 
CAUSES  AND  SYMPTOMS  OF  FEVER 

FEVER  is  a  disturbance  of  the  heat  mechanism  in  which 
there  is  a  more  or  less  prolonged  rise  of  temperature  above 
the  normal.  The  principal  cause  is  the  circulation  of  unusual 
toxic  substances  in  the  blood.  It  is  the  result  of  a  protective 
effort,  an  attempt  on  the  part  of  the  body  to  cope  with  these 
poisons;  but  the  organism  may  be  overwhelmed  by  them  and  so 
be  unable  to  oxidize  them  with  sufficient  rapidity  to  protect  the 
body.  Or,  because  of  the  nature  of  these  poisons,  the  heat- 
regfulatingf  centers  and  the  vasomotor  centers  are  disturbed  and 
the  balance  unsettled.  If  heat  elimination  were  to  keep  pace 
with  the  heat  production,  even  though  the  latter  were  greatly 
increased,  there  could  be  no  rise  of  temperature.  Many  toxines 
cause  a  sensation  of  chilliness  and  tlrus  decrease  the  heat  loss, 
and  fever  results.  While  the  body  attempts  to  protect  itself, 
its  efforts  are  not  always  well  directed  or  governed. 

The  poisons  producing  pyrexia  are  of  various  origin.  They 
may  be  formed  in  the  body  or  introduced  from  without.  In  the 
former  case  the  toxemia  may  be  due  to  the  accumulation  of 
body  poisons,  i.  e.,  those  which  are  normally  produced  in  health 
by  ordinary  metabolism,  but  are  usually  eliminated  as  fast  as 
formed.  These  poisons  are  called  leucomaines .  They  do  not 
produce  the  higher  types  of  fever,  nor  fever  of  long  duration. 
The  poisons  due  to  anger,  worry,  and  other  nervous  disturb- 
ances are  classed  under  this  head,  although  they  are  not  normal 
to  the  body. 

Prominent  among  the  leucomaines,  as  a  cause  of  fever,  are 
the  purin  bases.  Apropos  of  this  subject  we  quote  the  follow- 
ing from  Lusk: — ' 

1     Science  of  Nutrition.  1906.  p.  267. 
(160) 


CAUSES  OF  PYREXIA  161 

"  However,  there  is  a  very  noteworthy  record  made  by  A.  R. 
Mandel  that  the  rise  of  temperature  in  aseptic  or  surgical  fevers 
is  accompanied  by  a  largfe  increase  in  the  purin  bases  in  the 
urine  of  patients  fed  with  milk.  The  temperature  rises  and 
falls  with  the  quantity  of  purin  bases  eliminated.  The  uric 
acid  elimination  is  reduced. 

'  That  the  purin  bases  can  be  the  cause  of  the  rise  of  tem- 
perature is  indicated  by  the  experiments  of  Burian  and  Schur 
who  found  that  when  nucleoproteid  was  administered  intraven- 
ously to  a  dog-  a  rise  of  temperature  followed.  Mandel  showed 
that  a  subcutaneous  injection  of  40  milligrams  of  xanthin  caused 
a  marked  rise  in  the  temperature  of  a  monkey,  and  that  the 
administration  of  a  strong  decoction  of  60  grams  of  coffee  (con- 
taining trimethyl-xanthin)  to  a  man  unused  to  coffee-drinking, 
was  followed  by  a  febrile  temperature." 

Toxines  may  be  produced  by  saprophytic  bacteria  (those  of 
decomposition),  growing  in  the  body  or  in  the  alimentary  tract. 
These  conditions  are  known  as  sapremia  and  auto -intoxication. 
Foods  decomposed  by  bacterial  action  may  serve  as  the  source 
of  poison,  as  in  the  eating  of  decomposed  meat,  cheese,  etc. 
Such  products  of  bacterial  decomposition  are  known  as  pto- 
maines. Bacterial  toxines  produced  by  pathogenic  bacteria, 
growing  within  the  body  itself,  are  the  most  usual  causes  of 
fever  and  those  with  which  we  are  most  concerned  in  the  treat- 
ment of  this  condition. 

Ultimate  Causes  of  Pyrexia.  The  following  outline  is  modi- 
fied and  abridged  from  Sollmann.2 

Fever  may  be  due  to, — 

1.  Exposure  to  excessive  external  heat  as  in  sunstroke.     Also 
internal  heat  (over-oxidation)  as  in  excessive  muscular  exercise. 

2.  Certain  drugs,  such  as  the  convulsants,  cocaine  and  strych- 
nine, by  the  production  of  convulsions  or  spasm  of  the  muscles. 

3.  Toxic  proteins. 

(a)  Bacterial  toxines  of  infectious  diseases. 

(b)  Ptomaines. 

(c)  Auto-intoxication  (intestinal,  biliary,  urinary,  etc.). 

2    Text  Book  of  Pharmacology.  1901,  p.  394. 
11 


162  FEVER  AND  ANTIPYRETIC  EFFECTS 

(d)  Absorption  of  unconverted  digestive  products,  as  albu- 
moses  and  peptones  in  a- diet  too  rich  in  proteid;  or  due  to 
digestive  disorders. 

Manifestations  of  Fever.  In  addition  to  the  causes  of  fever, 
it  is  necessary  to  consider  the  symptoms,  since  these  are  an 
indication  of  the  real  condition  of  the  patient  and  may  be  of 
such  a  magnitude  as,  in  turn,  to  become  a  cause  of  additional 
trouble;  in  which  case,  special  treatment  must  be  directed 
toward  their  relief  or  palliation. 

The  toxines,  or  the  high  temperature,  cause  the  following 
symptoms,  recognized  as  characteristic  of  fevers: — 

1.  Nervous  disturbances,  such  as  malaise,  headache,  back- 
ache, insomnia,  delirium,  etc. 

2.  Hot  dry  skin,  or  cold  clammy  skin. 

•3.  Increased  pulse  rate  and  blood  tension. 

4.  Increased  rate  of  respiration. 

5.  Excessive  thirst. 

6.  Loss  of  appetite,  foul  breath,  coated  tongue. 

7.  Constipation. 

8.  Urine   scanty,  highly  colored,   high   specific  gravity,  in- 
crease of  urea. 

PRINCIPLES  OF  TREATMENT 

Since  oxidation  is  one  of  the  means  of  getting  rid  of  toxines, 
this  burning  is  to  be  encouraged  rather  than  hindered.  The 
fever  should  be  controlled,  not  combated.  The  system  is  to  be 
aided  in  its  attempt  to  oxidize  and  eliminate  the  poisons.  This 
is  where  failure  in  the  protective  mechanism  is  especially  mani- 
fest in  febrile  diseases.  While  the  decomposition  and  destruc- 
tion of  body  tissue  is  much  increased  in  fever,  true  oxidative 
changes  are  nearly  always  decreased.  For  this  reason  the 
system  is  compelled  to  cope  not  only  with  the  toxines  of  direct 
bacterial  origin  but  also  with  those  of  decomposition  and  incom- 
plete metabolism. 

The  idea  that  the  reduction  of  temperature  is  the  sole  object 
in  the  treatment  of  fevers  has  become  so  firmly  fixed  in  the 
minds  of  physicians  and  laymen  that  it  is  hard  to  eradicate. 
It  was  this  idea  that  led  to  the  use  of  the  medicinal  antipyretics, 


163 

the  giving'  of  which  is  not  only  wholly  irrational ,  -but  productive 
of  very  serious  complications  and  sequellae.  To  a  great  extent, 
the  same  idea  also  prevails  with  regard  to  the  use  of  the  cold 
bath  in  fever,  much  to  the  discredit  of  hydrotherapy  and  rational 
therapeutics.  Many,  too,  regard  the  reduction  of  fever  as  the 
only  asset  of  hydrotherapy,  and  fever  as  the  only  condition  in 
which  hydriatic  measures  are  applicable.  That  both  ideas  are 
erroneous  has  already  been  shown  and  will  be  made  plainer  as 
we  consider  the  rationale  and  results  of  hydrotherapy,  not  only 
in  fever,  but  in  a  host  of  other  maladies. 

The  basic  object  in  the  treatment  of  fevers  is  the  same  as  in 
all  other  diseases,  viz.,  the  removal  of  the  cause.  This  can  be 
accomplished  only  by  decreasing  the  toxemia.  In  only  a  few 
febrile  diseases  has  medical  science  discovered  a  direct  anti- 
toxine  or  perfected  a  workable  system  of  producing  immunity. 
We  are,  therefore,  under  the  necessity  of  directing  our  efforts 
toward  increasing  the  oxidation  and  hastening  the  elimination 
of  these  bacterial  toxines;  increasing  phagocytosis;  and  assist- 
ing and  conserving  the  powers  of  the  tissues  in  the  production 
of  antitoxines,  antibodies,  opsonin,  etc.,  this  latter  action  being 
largely  the  work  of  the  phagocytes  themselves,  upon  the  integ- 
rity and  activity  of  which  immunity  depends  (Metchnikoff). 

In  addition  to  this  basic  object — the  removal  of  the  cause — it 
is  necessary  to  prevent  the  over  accumulation  of  heat,  a  thing 
which  is  accomplished  by  the  same  means.  And  third,  to  miti- 
gate the  symptoms,  especially  those  referable  to  the  nervous 
system;  combat  headache,  malaise,  insomnia,  delirium,  etc. 
This  also  is  done  by  the  cold  bath  and  other  cold  applications. 
In  fact,  all  of  these  results  can  be  and  are  obtained  by  properly 
applied  hydriatic  measures  as  has  been  demonstrated  by  the 
experiments  cited  in  the  previous  part  of  this  work. 

RATIONALE  OF  HYDROTHERAPY  IN 
INFECTIOUS  FEVERS 

The  principal  object  to  be  sought  in  the  treatment  of  fever  is 
the  combating  of  the  infection.  The  antiseptic  treatment  of 
infections  has  proven  a  failure.  There  are  no  germicides 
known  which  have  given  anything  like  even  moderate  success 


164  FEVER  AND  ANTIPYRETIC  EFFECTS 

in  dealing  with  bacteria.  A  few  like  hexamethylenamin  are 
valuable  aids,  but  of  limited  range.  The  chemical  destruction 
of  bacteria  within  the  human  organism  is  a  disappointment  and, 
as  remarked  by  one,  "  we  aim  at  the  germs  and  hit  the  patient. ' ' 
The  organism  is  hindered  more  than  it  is  helped.  Concerning 
methods  of  treating  infections  W.  J.  Mayo3  has  the  following 
to  say:  "  Experience  soon  taught  us,  however,  that  in  combat- 
ing infectious  disease,  it  is  even  more  important  that  we  famil- 
iarize ourselves  with  those  conditions  of  the  body  by  which 
nature  combats  disease."  Upon  the  physicians  knowledge  of 
these  natural  methods  depends  to  a  large  extent  his  ability  to 
employ  physiologic  therapy  in  a  rational  way. 

The  body  itself  must  be  aroused  to  combat  the  infection. 
This  is  most  effectually  accomplished  by  those  means  which 
increase  the  vital  resistance  of  the  body,  conserving  its  power, 
and  especially  by  those  means  which  increase  the  number  and 
efficiency  of  the  phagocytes.  It  has  already  been  shown  how 
this  may  be  accomplished.  It  will  also  be  noted  that  cold 
applications  as  suited  to  the  varying  needs  of  different  diseases, 
compass  all  of  these  results.  We  have  seen  that  cold  produces 
a  leucocytosis,  restores  the  diminished  alkalinity  of  the  blood, 
produces  an  active  arterial  hyperemia,  increases  and  sustains 
blood  pressure,  so  that  life  giving,  energizing  blood  circulates 
more  rapidly  where  previously  there  was  stasis,  venous  hyper- 
emia, leucopenia,  lowered  alkalinity,  and  a  blood  laden  with 
leucomaines,  toxines,  and  acid  poisons.  The  elimination  of 
toxic  products  of  bacterial  life  is  hastened  and  their  oxidation 
increased  by  cold.  The  phagocytes  and  body  tissues  are  so 
energized  that  the  histogenous  production  of  antitoxines,  bac- 
teriolysins.opsonin,  etc.,  is  increased.  While  all  these  changes 
are  being  brought  about,  the  lessened  toxicity  of  the  body  fluids 
relieves  the  nervous  system  and  it  is  quieted  and  invigorated 
by  the  tonic  influence  of  the  cold.  Restlessness,  insomnia, 
or  delirium  gives  way  to  clear  coordinated  action  or  undis- 
turbed sleep.  The  hot  dry  skin,  or  the  cold  clammy  skin,  is 
replaced  by  the  warm  moist  surface.  This  remarkable  group 
of  changes,  all  of  which  are  beneficial  and  derived  from  a  single 

3    Mayo  Clinic.  1910,  p.  118. 


TOXIC  VASOMOTOR  PARALYSIS  165 

agent — cold  water — it  is  impossible  to  bring  about  by  any  other 
known  therapeutic  agent  or  combination  of  agents.  It  is  simply 
unique  in  the  realm  of  therapy. 

Toxic  Vasomotor  Paralysis.  Further  in  regard  to  the  con- 
nection of  the  circulatory  system  with  the  general  manifesta- 
tions of  fever  and  especially  with  regard  to  the  circulatory 
complications  which  contribute  so  largely  to  the  mortality, 
experimental  pathology  has  laid  a  very  firm  foundation  for  the 
use  of  hydrotherapy  in  fevers  of  infectious  origin.  The 
researches  of  Romberg  and  Passler  are  considered  the  basis  of 
our  knowledge  of  the  state  of  the  heart  and  blood-vessels  in 
these  diseases.  The  reports  of  their  work  4  have  shown  con- 
clusively that  circulatory  failure  is  not  primarily  due  to  the 
heart  itself,  but  to  paralysis  of  the  blood- vessels,  brought  about 
by  damage  to  the  vasomotor  centers.  In  this  connection  we 
can  not  do  better  than  quote  from  the  brief  resume  of  these 
researches  given  by  Janeway  and  from  remarks  made  by 
Forchheimer.5 

'  They  studied  the  fatal  collapse  which  occurred  in  rabbits 
after  infection  with  the  pneumococcus,  the  bacillus  pyocyaneus, 
and  the  diphtheria  bacillus;  the  first  producing  a  true  septi- 
caemia, the  latter  a  local  lesion  with  general  toxaemia.  All  of 
the  250  animals  used  were  autopsied,  and  the  heart  and  other 
important  organs  examined  microscopically.  Their  method 
consisted  in  observing  the  mean  carotid  pressure  at  different 
stages  of  the  disease,  and  the  effect  upon  it  of  (l)  abdominal 
massage,  which  increased  the  work  of  the  heart  by  supplying 
it  with  more  blood;  (2)  compression  of  the  aorta  above  the 
diaphragm,  which  makes  the  work  of  the  heart  maximal; 

(3)  irritation  of  the  nasal  mucous   membrane  with  a  Faradic 
current,    which    causes    extreme   reflex    vasoconstriction;    and 

(4)  short  asphyxia  (thirty  seconds) ,  which  acts  similarly  only  on 
both   medullary  and  spinal   vasomotor  centers;  while  sensory 
stimulation    affects    only   the    center   in    the    medulla.      They 
reasoned  that,  should  there  be  no  rise  in  pressure  from  sensory 


4  Rombsrg  and  Passler— Deutsch.  Archiv.  fur  klin.  Med.,  1895,  LXIV,  pp.  652—763;  also 
Passler— Mum-hen.  Med.  Wochenschrift,  1901,  XLVIII.  No.  8. 

5  The  Clinical  Study  of  Blood  Pressure,  pp.  155,  156;  and  Cardiac  and  Vascular  Com- 
plications in  Pneumonia— Journal  of  American  Medical  Association,  Oct.  30,  1909,  p.  1450. 


166  FEVER  AND  ANTIPYRETIC  EFFECTS 

irritation  or  suffocation,  while  abdominal  massage  and  ligature 
of  the  aorta  still  called  forth  a  well  marked  one,  then  the  heart 
must  be  functionally  capable  and  the  vasomotor  mechanism 
paralyzed.  To  determine  whether  the  central  or  peripheral 
vasomotor  mechanism  was  at  fault,  they  used  injections  of 
barium  chloride,  which  cause  constriction  of  the  arteries  by 
purely  local  action  upon  them. 

' '  Their  experiments  showed  that  the  blood  pressure  and  the 
response  to  all  the  procedures  remained  perfectly  normal 
throughout  the  early  stage  of  the  disease,  being  unaffected  by 
the  fever.  The  greatest  elevation  of  pressure  was  obtained  on 
stimulating  the  mucous  membrane  of  the  nose.  When  the 
animals  showed  signs  of  impending  collapse  in  their  behavior, 
the  blood  pressure,  though  still  normal,  began  to  sink,  while 
the  heart  beat  more  forcibly.  Hand  in  hand  with  this  went  a 
great  reduction  in  the  rise  of  pressure  from  sensory  irritation, 
a  moderate  decrease  in  the  asphyxial  elevation,  but  as  high  a 
pressure  as  before  after  abdominal  massage.  In  many  cases 
the  pressure  did  not  fall  until  the  reflex  rise  had  been  almost 
abolished,  evidently  being  maintained  by  increased  cardiac 
energy,  in  spite  of  the  vascular  dilatation.  Finally  in  complete 
collapse,  which  developed  very  rapidly,  the  aortic  pressure  fell 
to  the  lowest  level,  as  after  destruction  of  the  spinal  cord;  no 
reflex  rise  could  be  obtained,  but  abdominal  massage  gave  an 
immediate  elevation.  It  was  evident,  therefore,  that  the  circu- 
latory disturbance  at  the  height  of  the  infection  depended  absolutely 
upon  a  paralysis  of  the  vessels,  not  upon  any  damage  to  the  force 
of  the  heart. 

' '  As  regards  their  reaction  to  compression  of  the  thoracic 
aorta,  the  diphtheria  animals  showed  a  divergence  from  the 
pneumococcus  ones;  the  latter  evincing  practically  normal 
cardiac  reserve  force,  while  the  former  showed  a  distinct  fall- 
ing off.  Anatomically,  also,  the  diphtheria  hearts  had  suffered 
damage,  parenchymatous  degeneration  being  well  marked,  as 
in  clinical  diphtheria.  The  pneumococcus  animals  had  scarcely 
any  change  in  their  cardiac  muscle.  Thus  evidence  of  weak- 
ness in  the  heart  muscle  in  diphtheria  was  of  minor  importance, 
the  real  cause  of  death  in  all  cases  being  the  complete  loss  of 


TOXIC  VASOMOTOR  PARALYSIS  167 

vasomotor  tone.  By  intravenous  injections  of  barium  chloride 
they  proved  decisively  that  this  was  due  to  central  paralysis. 
Their  conclusions  were,  that  all  three  organisms  used  damage 
the  circiilation  through  paralysing  the  vasomotor  centers 
throughout  the  medulla  and  cord;  this  vasomotor  paralysis 
leads  to  a  fall  in  blood  pressure,  and  further,  to  a  changed 
blood  distribution;  the  splanchnic  circulation  is  overfilled,  the 
brain,  muscle,  and  skin  vessels  are  empty;  the  heart  is  not 
affected,  except  secondarily  through  insufficient  blood  supply." 

Forchheimer's  discussion  on  this  latter  condition — splanchnic 
congestion — is  as  follows:  "Long  ago  it  has  been  shown  in 
animals,  that  on  section  of  the  splanchnic  nerve,  an  enormous 
quantity  of  blood  accumulates  in  the  intestine,  which  is  followed 
by  intense  anemia  in  other  organs,  especially  in  the  central 
nervous  system,  which  may  cause  death.  The  splanchnic  nerve 
is  the  vasomotor  nerve  of  the  intestines,  and  its  section  causes 
paralysis  of  vasomotor  function  and  enormous  dilatation  of  the 
blood-vessels.  In  paralyzing  the  vasomotor  center  with  the 
pneumococcus  the  same  result  follows  in  man.  In  brief,  in 
man  there  is  first,  dilatation  of  blood-vessels  in  the  splanchnic 
area;  the  blood  pressure  which  sooner  or  later  is  normally  low 
in  pneumonia,  sinks;  the  heart,  which  is  supplied  by  an  insuf- 
ficient quantity  of  blood,  which  is  gradually  becoming  station- 
ary in  the  affected  area,  continues  to  draw  blood  from  other 
places,  the  liver,  the  skin,  the  muscles  and  central  nervous 
system,  and  becomes  more  and  more  rapid  and  ineffectual, 
'bleeding  itself  into  the  splanchnic  area,'  and  finally  stops. 
The  intracardiac  pressure  is  reduced  so  that  the  myocardium 
ceases  to  contract,  moreover,  the  various  cardiac  and  vasomotor 
centers  become  asphyxiated,  and  therefore  paralyzed." 

By  reference  to  the  chapter  on  blood  pressure  in  the  first 
part  of  this  work  it  will  be  seen  that  the  above  quoted  facts  and 
discussion  very  clearly  demonstrate  the  rationale  of  hydro- 
therapy  in  infectious  diseases,  and  clinical  experience  has 
proven  what  experiment  has  demonstrated.  The  vasomotor 
stimulation  which  results  from  hydriatic  procedures  amply 
meets  the  needs  of  the  situation,  which  need  it  is  impossible  to 
meet  by  medicinal  therapy  of  any  sort. 


168  FEVER  AND  ANTIPYRETIC  EFFECTS 

THE  EFFECTS  OF  MEDICINAL  ANTIPYRETICS 

/.  Drugs  having  a  Collapse  Action,  such  as  Aconite  and  Viratnun 
Viride.  These  lessen  the  force  of  the  heart  beat  and  dilate  the 
blood-vessels,  so  lowering  the  blood  pressure.  Heat  production 
is  decreased,  because  of  this  latter  action.  Vasodilatation  favors 
the  loss  of  heat  from  the  skin.  This  is  not  a  tonic  but  an  atonic 
dilatation  and  so,  in  no  way  restores  the  lost  tone  to  the  circu- 
latory system.  Both  these  drugs  decrease  fever  at  the  expense 
of  the  heart's  action  and  so  prove  dangerous  in  asthenic  fevers, 
or  where  there  is  cardiac  weakness,  dilatation,  or  incompetency 
already  existing. 

2.  Alcohol.  The  only  beneficial  (?)  action  of  alcohol,  as  re- 
lied upon  in  fever  and  as  given  in  so-called  therapeutic  doses, 
is  upon  the  smaller  blood-vessels,  in  which  it  causes  an  atonic 
or  paretic  dilatation  and  consequent  loss  of  heat  from  the  skin. 
At  the  same  time,  it  dilates  the  visceral  capillaries  which  arc 
already  congested  in  febrile  conditions.  Their  paretic  condi- 
tion renders  the  viscera  much  more  liable  to  suffer  from  retro- 
stasis  when  the  body  is  exposed  to  cold.  Alcohol  decreases 
metabolic  processes  and  oxidation.6  The  tissues  are  less  active 
so  that  toxines,  instead  of  being  more  rapidly  oxidized  and 
eliminated,  tend  to  accumulate  in  the  system.  Alcohol  lessens 
the  phagocytic  activity, — the  natural  defence  against  infection, 
and  discharges  immunity.  Delearde  has  shown  that  the  ab- 
sorption of  alcohol  is  a  grave  obstacle  to  immunization  against 
hydrophobia.  Abbot,  in  experimenting  on  animals,  proved 
that  those  subjected  to  the  influence  of  alcohol  were  more  sus- 
ceptible to  the  harmful  effects  of  streptococci,  bacillus 'coli  and 
other  bacteria.  Both  Delearde  and  Laitinen  found  it  impos- 
sible to  vaccinate  against  anthrax,  animals  that  had  been  given 
alcohol  on  several  successive  days. 

•  3.  The  Coal  Tar  Products,  as  Acetanilid,  Phenacetin,  and  Anti- 
fyyrin.  These  decrease  heat  production  by  the  direct  toxic 
action  of  their  aromatic  radicles  on  the  heat  centers  in  the 

"Alcohol  in  excessive  doses  and  prolonged  anaesthesia  both  paralyze  the  heat-regu- 

tianism      A  man  who  is  'dead  drunk'  resembles  a  cold  blooded  animal;  ex- 

to  cola  produces  not  an  increase  but  a  decrease  in  combustion,  and  his  tempera- 

tlily  falls.    It  is  not  surprising,  therefore,  that  death  from  exposure  chiefly  oc- 

e  case  of  intoxicated  persons."     (Hutchison— Applied  Physiology.  1908,  p.  67.) 


MEDICINAL  ANTIPYRETICS  169 

brain  and  on  the  processes  of  oxidation  and  proteid  metabolism.7 
This  is  shown  by  the  decrease  in  tissue  destruction,  lessening 
of  urea,  etc.  This  effect  is  most  marked  in  fever,  where  the 
rational  procedure  is  to  increase  the  burning1  up  of  poisons, 
(purins,  toxalbumens,  bacterial  toxines,  etc.)  in  order  to  get 
rid  of  them.  Neither  do  these  drugs  increase  the  elimination 
of  poisons.  They  are  very  powerful  cardiac  depressants  and 
possess  a  decided  collapse  action.  This  is  most  marked  with 
acetanilid.  They  cause  breaking  up  of  the  red  cells  with  the 
formation  of  methemoglobin,  thus  in  a  second  way,  preventing 
oxidation  by  limiting  the  oxygen-carrying  capacity  of  the  blood. 
The  movements  of  the  whites  are  arrested.  Phagocytosis  is 
prevented.  This  is  another  example  of  drugs  that  render  the 
body  less  able  to  resist  infection. 

4.  Qidnine.  This  drug  lowers  temperature  by  decreasing 
heat  production.  Its  action  is  said  to  be  chiefly  peripheral 
upon  the  thermogenic  tissues,  in  decreasing  nitrogenous  met- 
abolism. This  decrease  may  reach  as  high  as  39  per  cent 
with  large  doses.8  The  drug  probably  owes  its  toxicity  to  its 
aromatic  nucleus,  the  same  as  the  coal  tar  products.  It  not 
only  hinders  the  destruction  of  nitrogenous  toxines,  but  is  a 
powerful  poison  to  the  phagocytes,  arresting  their  movements 
immediately  on  contact  with  them.  This  result  obtains  when 
only  0.5  to  1  part  in  1000  of  solution  is  used.  A  somewhat 
larger  dose  causes  their  destruction  (Binz,  Sollmann).  Accord- 
ing to  recent  experiments  by  Man  waring  and  Ruh,  larger 
amounts  than  0.008  per  cent  of  quinine  cause  complete  sup- 
pression of  phagocytosis.  Since  1-13  of  the  body  weight  is 
blood,  an  individual  weighing  130  pounds  possesses  10  pounds 
of  blood,  totalling  70,000  grains.  If,  at  any  one  time,  there 
should  be  in  the  blood  of  a  person  of  this  weight,  ten  grains  of 
quinine,  there  would  then  be  acting  upon  the  phagocytes  an 
amount  nearly  double  the  minimum  toxic  dose.  Quinine  fre- 
quently causes  hemoglobinuria.  Metchnikoff9  makes  the  fol- 
lowing statement:  "It  is  not  only  opium  and  alcohol  which 

7     White  and  Wilcox—  Materia  Medica  and  Therapeutics,  1900,  p.  300;  also  Sollmann— 
Text  Book  of  Pharmacology,  1901,  p.  355. 


,          , 

t  Book  of  Pharmacology,  1901,  p.  355. 

Sollmann—  Ibid,  p.  346.     See  also  Adami—  Inflammation,  1907,  p.  152. 
New  Hygiene,  p.  28. 


770  FEVER  AND  ANTIPYRETIC  EFFECTS 

hinder  the  phagocytic  action.  A  number  of  other  substances 
regularly  employed  in  medicine,  cause  the  same  results.  Even 
quinine,  the  .  .  .  effect  of  which  in  malarial  fevers  is  indisput- 
able, is  a  poison  for  the  white  blood  cells.  One  should,  there- 
fore, as  a  general  rule,  avoid  as  far  as  possible  the  use  of  all 
sorts  of  medicaments,  and  limit  one's  self  to  the  hygienic 
measures  which  may  check  the  outbreak  of  infectious  disease. 
This  postulate  further  strengthens  the  thesis  that  the  future  of 
medicine  rests  far  more  in  hygiene  than  therapeutics." 

5.  Diaphoretics,   as  Pilocarpin   and  .Dover's    Powder.       These 
lower   febrile   temperature   by    producing    sweating.     This   in 
itself,  is   not   irrational.     In   the    case    of   the    former,  it  has 
recently  been  shown  that  this  is  at  the  expense  of  the  heart's 
action.     The  latter  drug  contains  opium  which  has  the  same 
action  on  the  phagocytes  as  alcohol,  quinine,,  and  coal  tar  pro- 
ducts. 

6.  Refrigerants,  such  as  the  Alkaline  Citrates,  Organic  Acids, 
and  Add   Organic   Salts.     The    alkalescence    of   the    blood   is 
diminished  in  auto-intoxication  and  infectious  diseases.     Bou- 
chard failed  to  neutralize  the  excess  of  acid  in  the  blood  by  the 
administration  of  inorganic  alkalies.     The  citrates,   tartrates, 
etc.,  do,  however,  favor  kidney  activity  (diuresis)  and  sweat- 
ing  (diaphoresis),  and   so   aid  in    the  elimination  of  toxines. 
Experience  demonstrates  that  the  natural  fruit  juices,  contain- 
ing these  acids  and  "their  salts,   give  better  results  in  these 
respects  than  artificial  preparations  and  do  possess  a  true  re- 
frigerant action. 

No  great  discernment  is  necessary  to  decide  that  antipyretic 
drugs  are  harmful  in  fever.  The  majority  of  fevers  are  due  to 
infections,  i.  e.,  are  bacterial  toxemias.  These  drugs  in  no 
way  remove  the  cause,  nor  do  they  assist  the  body  to  over- 
come the  infection.  On  the  contrary,  they  destroy  or  cripple 
the  agents  of  natural  defense — the  leucocytes,  rendering  them 
an  easy  prey  to  bacteria. 

ANTIPYRETIC  EFFECTS  OF  THERMIC  APPLICATIONS 

Let  us  now  turn  our  attention  to  the  differences  in  the  effects 
of  the  various  thermic  applications  used  in  the  treatment  of 
fevers.  The  following  classification  will  be  found  helpful: — 


HYDRIATIC  ANTIPYRETICS  171 

1.  Applications  of  cold. 

(a)  Prolonged — direct    antipyretic,    by    abstracting    more 
heat  than  is  produced. 

(b)  Short — stimulate  heat  production  as    much    or   more 
than  they  increase  heat  elimination. 

2.  Applications  of  heat. 

(a)  Prolonged — antipyretic  by  increasing  heat  elimination 
through  profuse  sweating. 

(b)  Short — an  adjuvant,  prepares  the  body  for  cold  appli- 
cations. 

The  physiologic  effects  of  the  four  classes  may  be  studied 
under  the  two  following  heads: — 

1.  Effect  on  heat  production. 

2.  Effect  on  heat  elimination. 

Prolonged  Cold.  The  Brand  bath  may  be  taken  as  a  type  of 
this  class  of  hydriatic  antipyretics,  the  effects  of  which  are  as 
follows: — 

1.  Heat  production  is  decidedly  increased.     This  is  due  to 
the  thermic  stimulus  arising  from  contact  with  the  cold  water. 
Oxidation    and    nitrogenous    metabolism    are    both    increased. 
There  is  not  only  an  increase  in  the  oxidation  and  consequent 
destruction  of  poisons,  but  their  elimination  in  an  incompletely 
oxidized  state  is  hastened.     This  is  proven  by  the  decided  in- 
crease in  the  toxicity  of  the  urine  after  a  cold  bath,  as  shown 
by  Bouchard,  Roque  and  Weil. 

2.  Heat  is  transferred  from  the  body  to  the  water  and  in 
greater  quantity  than  the  heat  produced,  so  that  a  fall  of  tem- 
perature results.     This  is  made  doubly  necessary  because  of 
the  above  mentioned  increase  in  heat  production  which  would 
tend  to  increase  the  height  of  the  fever  if  it  were  not  combated . 
This  is  by  purely  mechanical  means,   i.  e.,  conduction.     The 
heat  of  the  body  is  transferred  to  the  water  which  will  take  up 
an  exceedingly  large  amount  without  being  greatly  warmed. 

Heat  elimination  is  increased  by  friction,  i.  e.,  the  body  is 
constantly  kept  in  a  condition  favoring  the  abstraction  of  heat. 
The  rubbing  produces  vasodilatation  and  quickens  the  circula- 
tion. These  conditions  bring  more  blood  to  the  surface  which 
is  exposed  to  the  cold  water.  The  same  conditions  and  the 


172  FEVER  AND  ANTIPYRETIC  EFFECTS 

friction  itself  serve  to  give  a  sensation  of  warmth  to  the  skin 
and  so  prevent  chilling:  and  the  resulting:  retrostasis  of  blood. 

Indications.  These  effects  are  indicated  in  long-  continued 
asthenic  fevers,  such  as  typhoid,  typhus  and  in  hyperpyrexia. 
The  treatment  must  be  frequently  repeated  over  a  considerable 
length  of  time,  since  it  can  not  be  hoped  that  the  source  of  tox- 
emia will  be  eradicated  by  a  few  applications. 

Short  Cold  applications  are  almost  always  accompanied  by 
mechanical  stimuli.  The  cold  mitten  friction  is  the  best  ex- 
ample of  this  class. 

1.  Heat  production  is  increased  by  reason  of  the  action  of 
the  thermic  and  mechanical  stimuli  on  the  heat  centers. 

2.  The  contact  with  the  cold  water  is  of  too  brief  duration  to 
abstract  much  heat  from  the  body.     The  cooling  is  not  mani- 
fest except  on  the  skin.     Later,  heat  elimination  is  increased 
because  of  the  vascular  reaction  in  the  skin. 

Indications.  Short  sthenic  fevers,  as  grippe,  colds,  etc.,  or 
where  the  skin  is  cold  and  clammy,  for  the  purpose  of  warming 
the  skin  and  raising  the  blood  pressure.  This  sometimes 
occurs  in  typhoid. 

Long  Hot.  Any  of  the  sweating  treatments  used  in  fevers 
serve  to  illustrate  the  effects  of  this  class  of  measures. 

1.  Heat   production   is    increased    during   the    treatment    at 
least  to  some  extent.     The  atonic  reaction  which  follows  may 
result  in  decrease  of  heat  production. 

2.  Heat    is   communicated    to   the    body.     This  is  the  chief 
cause  of  the    initial    rise    of   temperature    before    perspiration 
becomes  well  established  and  general.     Later,  heat  elimination 
is  enormously  increased  because  of  the  increased  circulation  in 
the  skin  and  especially  by  the  evaporation  of  the  perspiration. 
This  latter  is  the  essential  effect  of  sweating  treatments. 

Indications.  Sweating  treatments  are  indicated  in  the  first 
stage  of  nearly  all  fevers,  /.  e.,  at  the  onset.  It  is  at  this  time 
that  the  initial  chill  occurs.  They  are  useful  at  this  stage  in 
such  fevers  as  measles,  influenza,  scarlet  fever,  etc. 

Short  Hot.  Fomentations,  short  hot  packs,  hot  sponging, 
and  the  hot  evaporating  wet  sheet  pack  are  examples  of  this 


HYDRIATIC  ANTIPYRETICS 


173 


class  of  antipyretics.  Their  special  advantage  is  the  preparing 
of  the  skin  to  properly  react  to  succeeding  cold  treatment. 
The  skin  is  warmed  and  heat  elimination  is  increased  through 
the  warming  effect.  Some  heat  is  communicated  to  the  body. 
Heat  production  is  little,  if  at  all  influenced.  Wherever  there 
is  chilliness,  cyanosis,  or  goose  flesh  in  febrile  disease,  some 
form  of  hot  application  must  be  used  before  resorting  to  cold, 
since  in  the  absence  of  the  former,  the  cold  may  have  a  de- 
cidedly adverse  effect. 

In  addition  to  the  effects  noted  in  the  general  classes  of  treat- 
ments discussed  above,  it  should  be  understood  that  by  proper 
variations  in  the  manner  of  giving  hydriatic  treatment,  it  is 
possible  to  produce  any  desired  effect  upon  the  heat  mechanism 

Temperature-raising  value. 


D  F 

W  H  R 

C  M  F 

C  T  R 

WS  R 

Brand 

Cold 

Bath 

Bath 

Temperature-lowering  value. 

Fig.  47.  Diagram  showing  quantitative  relation  between  the 
temperature-raising  and  the  temperature-lowering  capacity  of 
different  treatments. 

and  upon  febrile  temperature.  In  the  case  of  cold  treatments 
these  variations  are  produced  by  changes  in  the  degree  of 
friction  used  and  in  the  quantity  of  cold  water  brought  in  con- 
tact with  the  skin  surface.  The  more  the  friction  and  the  less 
the  contact  with  cold  water,  the  greater  the  temperature-raising 
capacity.  The  larger  the  amount  of  cold  water  brought  in 
contact  with  the  body,  provided  reaction  be  maintained,  the 
greater  the  temperature -lowering  capacity.  This  relation  is 
graphically  shown  in  Fig.  4-7 .  The  proportion  of  each  block 
below  the  cross  line  indicates  the  relative  value  of  the  treatment 
in  lowering  temperature  as  compared  with  its  temperature- 
raising  value  indicated  by  the  proportion  of  the  block  above 
the  line. 


174  FEVER  AND  ANTIPYRETIC  EFFECTS 

THE  HEAT  MECHANISM  IN  FEVER 
The  mechanism  of  the  production  of  fever  is  a  large  subject 
and  one  somewhat  outside  of  the  scope  of  this  work.  The  re- 
are,  however,  a  few  points  that  should  be  noted  in  order  to  grain 
an  understanding;  of  the  principles  involved  in  the  treatment 
of  fever,  /.  e. ,  in  order  to  treat  such  conditions  intelligently . 
Graham  Lusk 10  gives  the  following  discussion : — 
"A  high  fever  may  be  accompanied  by  an  increased  metabol- 
ism of  only  15  per  cent.  The  cause  of  the  fever  must  therefore 
be  due  to  diminution  in  the  ability  to  discharge  the  heat  pro- 
duced. In  further  support  of  this,  Senator  has  shown  that  the 
fever  following  pus  injections  in  a  dog  begins  with  a  retention 
of  heat  within  the  body.  Nebelthau  found  that  when  the  heat 
discharge  of  a  normal  rabbit  was  called  100,  during  the  first 
twelve  hours  of  infection  in  which  the  temperature  rose  from 
38.6° — 40.1°,  the  discharge  of  heat  was  but  96.3.  Assuming 
the  heat  production  to  have  been  the  same  in  these  two  periods 
(as  was  actually  the  case  in  the  rabbits  of  May),  then  the  heat 
retained  would  account  for  the  pathological  increase  in  tempera- 
ture. At  a  later  stage  the  discharge  of  heat  rose  to  equalize 
its  production  at  the  higher  temperature." 

In  the  state  of  lessened  heat  elimination  manifest  at  the 
beginning  of  most  fevers  lies  the  reason  for  the  initial  use  of 
hot  applications  so  frequently  advised  in  the  subsequent  pages 
of  this  work. 

'  Nebelthau  has  shown  a  fall  in  temperature  and  heat  pro- 
duction in  a  rabbit  whose  cord  was  divided  between  the  sixth 
and  seventh  cervical  vertebrae,  and  has  also  demonstrated  that 
under  these  circumstances  infection  with  erysipelas  of  the  pig 
had  no  influence  on  temperature  or  heat  production.  The  in- 
ference is  that  the  febrile  toxines  act  through  the  higher  vaso- 
motor  centers,  whose  regulatory  control  is  lost  in  the  above 
experiment. 

'  A  kindred  interpretation  may  be  placed  on  the  experiments 
of  Mendelsen,  who  was  unable  to  produce  fever  through  pus 
injections  when  the  dog  was  under  the  influence  of  chloral  or 
morphine,  although  such  treatment  in  a  normal  animal  caused 

10    Science  of  Nutrition,  p.  255. 


HEAT  MECHANISM  IN  FEVER  175 

a  rise  in  temperature  of  from  36.3° — 39.9°  in  forty-five  minutes. 
Mendelsen  also  finds  a  constant  constriction  of  the  renal  blood- 
vessels in  fever. 

"in  intermittent  fever  profuse  perspiration  is  certainly  an 
important  factor  in  the  reduction  of  temperature  at  the  end  of 
the  febrile  stage. 

"It  may  be  concluded,  as  Krehl  emphatically  states,  that 
insufficiency  of  water  evaporation  plays  a  not  unimportant  role 
in  the  febrile  rise  in  temperature.  The  body  might  be  cooled 
were  the  sweat  glands  freely  active. 

1  The  production  of  heat  in  fever  may  be  greatly  increased 
during  a  chill,  and  a  rapid  rise  in  temperature  may  follow. 
This  was  shown  by  Liebermeister  in  a  case  of  malaria.  The 
temperature  rose  from'  36.9°  in  the  first  half  hour  to  39.5°  at 
the  end  of  another  hour,  while  the  carbon  dioxide  expired  rose 
from  13.85  grams  to  34.20  grams  per  hour.  This  was  a  case  of 
chill  with  shivering.  This  increased  metabolism  is  due  to  the 
mechanism  of  chemical  regulation.  The  blood  is  driven  from 
the  skin  by  vasoconstriction,  those  end-organs  of  the  skin  which 
are  sensitive  to  cold  are  strongly  stimulated,  with  the  result 
that  there  is  a  reflex  increase  of  heat  production.  That  this  is 
true  is  shown  by  the  fact  that  if  the  cold  stimulation  be 
removed  by  supplying  a  warm  environment,  the  attending 
phenomena  pass  off  (Krehl)." 

VARIATIONS  THAT  PRODUCE  FEBRILE  TEMPERA- 
TURE AND  THEIR  RELATION  TO  TREATMENT 

Any  unbalancing  of  thermo-regulation  whereby  there  is  more 
heat  produced  than  is  eliminated  will  cause  a  rise  of  tempera- 
ture. It  will  be  seen  from  this  that  there  are  several  possible 
variations  in  these  two  elements  which  might  be  the  cause  of 
fever.  In  a  majority  of  fevers  the  greater  difficulty  at  first  is 
in  the  faulty  heat  elimination.  A  rise  of  temperature  will  fol- 
low any  of  the  conditions  listed  below: — 
Heat  Production  Heat  Elimination 

1.  Increased      -     normal 

2.  Increased  increased,  but  less  than  heat  production 

3.  Increased      -     decreased 

4.  Normal         -     decreased 

5.  Decreased          decreased,  but  more  than  heat  production 


176  FEVER  AND  ANTIPYRETIC  EFFECTS 

Clinical  Antipyresis.  These  variations  are,  perhaps,  largely 
of  theoretical  interest.  However,  there  is  a  practical  applica- 
tion to  be  made  of  the  signs  and  symptoms  which  indicate  a 
decided  over-production  of  heat  or  a  marked  decrease  in  heat  elimin- 
ation. The  former  centra-indicates  vigorous  tonic  measures, 
such  as  the  cold  mitten  friction,  which  are  not  accompanied  by 
heat  abstraction,  i.  e.,  more  or  less  prolonged  contact  with  cold 
water.  The  latter  are  of  especial  importance  in  revealing  a  con- 
dition which  absolutely  centra-indicates  the  use  of  long  cold 
applications,  and  in  many  cases  even  the  short  cold  friction  un- 
less preceded  by  hot  applications.  In  cases  of  pyrexia  the 
following  signs  indicate  a  great  increase  in  heat  production: — 

1.  Full  pulse  and  flushed  face. 

2.  A  hot  dry  skin. 

A  consideration  of  these  will  at  once  reveal  the  fact  that  a 
cold  mitten  friction  would  be  inappropriate,  since  it  has  no 
tendency  to  lower  blood  pressure,  also  because  the  treatment 
stimulates  heat  production;  but  the  contact  with  cold  water  is  of 
too  brief  duration  to  abstract  much  heat  from  the  body.  Neither 
would  a  hot  application  or  a  sweating  treatment  best  meet  the 
condition.  It  is  necessary  to  abstract  heat  from  the  body  by 
some  more  or  less  prolonged  cold  application. 

On  the  other  hand,  the  following  symptoms  show  a  decided 
decrease  in  heat  elimination: — 

1.  Cold  skin,  whether  dry,  or  moist  and  clammy. 

2.  Cyanosis. 

3.  Goose  flesh  appearance. 

4.  Chilly  sensations. 

5.  Shivering. 

Again,  consideration  of  these  conditions  reveals  the  fact  that 
cold  applications,  unless  accompanied  by  vigorous  friction,  and 
not  even  then  in  some  cases,  will  greatly  increase  the  anemia 
of  the  skin  and  the  internal  congestion  which  exists  because  of 
the  chilling.  In  these  cases  hot  applications  or  sweating  treat- 
ments must  be  used  until  the  cyanosis  is  overcome  and 
the  blood  brought  back  to  the  surface,  thus  relieving  the 
internal  congestion  and,  at  the  same  time,  imparting  a  sensa- 
tion of  warmth  to  the  body  and  consequently  checking  the 


THERAPEUTIC  CLASSIFICATION 


177 


shivering'.  This  is  also  indicated  in  the  first  stage  of  many 
fevers  where  the  chill  has  actually  begun  or  where  chilly  sen- 
sations indicate  its  approach.  In  this  case  the  hot  sweating- 
treatment  should  not  be  repeated,  at  least  not  frequently,  as  it 
.is  too  weakening.  Its  frequent  repetition  does  not  increase  the 
vital  resistance,  but  rather  decreases  it.  It  decreases  phagocy- 
tosis and  the  production  of  antibodies.  Malaria  is  an  exception 
to  the  general  rule  of  the  use  of  hot  treatment  at  the  onset. 
Here  it  is  a  detriment  rather  than  a  benefit.  On  the  other 
hand,  in  acute  nephritis  much  sweating  treatment  should  be 
used  all  through  the  course  of  the  disease. . 

In  general  then,  it  may  be  said  that  long  cold  applications 
should  be  used  where  great  increase  of  heat  production  is  the 
chief  cause  of  fever;  and  hot  applications  where  the  decided 
decrease  of  heat  elimination  is  a  prime  factor  in  the  fever. 


Symptoms 


Chief  condi- 
tion present 

Indications 


Table  of  Therapeutic  Classification 

Group  A  Group  B 

Full  pulse,  flushed  face,       Cold  skin,   wet  or  dry, 
hot  dry  skin  cyanosis,    goose  flesh, 

shivering 


Great  increase  in  heat 
production 

Abstract  heat    by  long 
contact  with  cold 


Treatment        Long  cold  applications 


A  decided  decrease  in 
heat  elimination 

Warm  the  skin,  combat 
internal  congestion 

Hot  applications  until 
blood  is  brought  back 
to  skin 


The  following  lists  of  hot  and  of  cold  treatments  are  those  that 
are  most  useful  in  fevers.  When  properly  selected  and  suited 
to  the  individual  case,  the  cold  treatments  meet  the  first  indi- 
cation and  the  hot  treatments  the  second  indication. 

Cold  applications  useful  in  febrile  conditions: — 

1.  Brand  bath. 

2.  Graduated  bath  with  friction. 

3.  Tepid  or  cool  bath. 

4.  Evaporating  wet  sheet  pack. 

5.  Cold  towel  rub. 

12 


178  FEVER  AND  ANTIPYRETIC  EFFECTS 

6.  Ice  rub. 

7.  Cold  sponging-. 

8.  Cold  affusions. 

9.  Cold  to  head  and  neck. 

10.  Ice  bag  or  cold  compress  to  heart. 

11.  Cold  compress  to  abdomen. 

12.  Cold  water  coils  to  head  and  abdomen. 

13.  Cold  rectal  irrigation  or  enema. 

14.  Cold  water  drinking. 

15.  Fresh  cold  air  in  the  sick  room. 

Hot  applications  which  may  be  used  to  reduce  fever  or  assist 
the  cold  applications: — 

1.  Hot  blanket  pack. 

2.  Hot  bath  (very  short). 

3.  Hot  evaporating  sheet. 

4.  Hot  sponging. 

5.  Fomentations  to  spine. 

6.  Fomentations  to  abdomen. 

7.  Hot  water  drinking. 

8.  Cold  mitten  friction   (reaction    simulates  the  effects  of  a 
hot  application). 


CHAPTER  XVII 

THE  TREATMENT  OF  FEVERS 

TYPHOID  FEVER 

TYPHOID  fever  is  an  acute  infectious  disease,  more  or  less 
self-limited,  characterized  pathologically  by  a  localized 
inflammation  of  the  lymphatic  structures  of  the  intestines  and  a 
general  distribution  of  the  bacteria  (bacteriemia) ;  clinically,  by 
fever  of  rather  long1  duration  which,  at  the  onset,  rises  gradu- 
ally in  stepladder-like  increase  and  gradually  subsides;  diarrhea, 
and  a  special  tendency  to  hemorrhage  and  perforation.  We  say 
that  the  disease  is  self-limited  because  it  is  one  of  those  infec- 
tions which  arouse  the  body  to  the  production  of  antitoxines, 
bacteriolysins,  ag-glutinins,  etc.,  so  that  when  the  system  has 
had  time  to  produce  these,  the  infection  is  overcome  and  the 
patient  recovers.  It  is  not  possible  to  abort  typhoid  fever  by 
therapeutic  means.  The  so-called  abortive  type  of  typhoid 
fever  is  due  to  some  peculiarity  of  the  individual  or  of  the 
infection  and  not  to  any  treatment. 

The  chief  object  to  be  accomplished  in  the  treatment  of 
typhoid  fever  is  not  the  reduction  of  the  temperature,  but  the 
sustaining-  of  vital  resistance  until  such  time  as  the  system  has 
had  opportunity  for  the  production  of  antibodies.  This  build- 
ing- up  of  vital  resistance  is  accomplished  chiefly  in  two  ways:— 
first,  by  increasing-  the  efficiency  of  the  protective  mechanism. 
This  is  accomplished  by  stimulating-  the  process  of  phagocy- 
tosis, i.  <?.,  increasing-  tyie  number  and  efficiency  of  the  leuco- 
cytes in  the  peripheral  circulation,  in  order  that  they  may 
combat  the  infection,  the  bacteria  themselves:  and  by  stimulat- 
ing- the  production  of -antibodies,  such  as  agglutinin ,  which  also 

(179) 


J80  TREATMENT  OF  FEVERS 

act  directly  upon  the  bacteria;  second,  the  decrease  of  the  tox- 
emia by  increasing-  the  oxidation  of  the  bacterial  toxines  and 
hastening-  their  elimination  in  an  incompletely  oxidized  state. 
The  body  poisons,  the  leucomaines,  are  taken  care  of  in  the 
same  way  and  by  the  same  means.  These  are  the  two  principal 
objects  to  be  attained  in  the  treatment.  The  reduction  of  tem- 
perature is  only  incidental  to  these  and  serves  as  a  practical 
guide  to  the  completeness  of  these  results.  However,  in  the 
use  of  medicinal  antipyretics,  the  degree  of  the  fever  in  no  wax- 
runs  parallel  with  the  accomplishment  of  these  essential  objects. 
With  both  quinine  and  the  coal  tar  products,  phagocytosis  is 
interfered  with,  if  not  wholly  abolished  and  the  toxemia  is 
increased  because  of  a  decrease  in  the  oxidation  and  elimination 
of  the  poisons.  Under  the  use  of  hydrotherapy,  rationally  em- 
ployed, typhoid  fever  presents  an  entirely  different  clinical  pic- 
ture from  that  which  we  have  been  taught  to  regard  ?s  charac- 
teristic of  this  disease.  The  cold  bath  meets  practically  ail  of 
the  conditions  and  symptoms  which  require  special  attention. 
The  heart  and  circulation  are  sustained  and  invigorated,  the 
nervous  system  is  aroused,  and  the  nervous  symptoms,  usually 
regarded  as  an  invariable  accompaniment,  either  do  not  appear 
or  are  mitigated  in  severity.  The  emunctories  are  sustained  so 
that  elimination  is  greatly  increased. 

Treatment 

Since  the  cold  friction  bath  is  the  best  means  of  treating 
typhoid,  our  consideration  of  this  disease  will  larg-ely  be  a  dis- 
cussion of  the  methods,  rationale,  and  results  of  this  measure. 
The  original  cold  friction  bath,  as  devised  by  Brand,  consists 
in  the  full  immersion  of  the  body  in  water  at  a  temperature  of 
not  less  than  65°  F.  nor  more  than  70°  F.  As  advised  by 
Brand,  it  continues  fifteen  minutes,  during  which  time  the  entire 
skin  surface  immersed  in  the  water,  with  the  exception  of  the 
abdomen,  is  rubbed  vigorously  by  the  attendants.  The  object 
of  the  friction  is  the  production  of  reaction  so  that  the  sensation 
of  chilliness  is  abolished,  and  the  circulation  of  the  skin  main- 
tained, thus  favoring  the  cooling  of  the  blood.  If  at  any  time 
the  patient  becomes  cyanotic,  or  real  chilling  occurs,  as  indi- 


TYPHOID  FEVER 


181 


cated  by  continued  shivering'  and  chattering:  of  the  teeth,  he 
must  at  once  be  removed  from  the  bath.  The  Brand  bath  is  to 
be  repeated  whenever  the  temperature  of  the  patient  exceeds 
102.5°  or  103°  F.  In  practice  it  has  been  found  that  this  means 
every  three  or  four  hours. 

As  to  the  appliances  necessary,  it  has  been  found  that  some 
form  of  portable  bath  is  most  convenient.  Of  these,  there  are 
two  forms  worthy  of  description, — the  bath  tub  on  wheels  and 
the  bed  tub.  The  former  (.Plate  V.}  is  of  ordinary  bath  tub 


Fig.  48.    Burr  portable  bath.    A— frame,    B — complete. 

construction  and  sufficient  in  length  to  allow  the  full  extension 
of  the  patient  while  immersed  in  the  water,  and  of  such  depth 
that  the  patient  is  covered  with  water  up  to  the  chin.  This  tub 
can  be  wheeled  to  the  side  of  the  bed,  being"  placed  a  sufficient 
distance  from  the  side  of  the  bed  to  allow  of  two  attendants 
reversing-  the  patient  in  carrying-  him  from  the  bed  to  the  bath, 
or  it  may  be  placed  close  to  the  bed  and  the  patient  lowered 
directly  into  the  tub  by  hand  or  by  means  of  a  special  raising- 
and  lowering  device  (Plate  £Y. ). 

The  Burr  portable  bath  (Fig.  48.}  is  probably  the  best  type 
of  the  bed  bath.     It  consists  of  two  parts — a  largfe  rubber  sheet 


182  TREATMENT  OF  FEVERS 

with  rings  near  the  margin  for  fastening  to  the  frame  by  tapes, 
and  a  light  wooden  crib  capable  of  being  folded  into  a  compact 
bundle.  The  rubber  sheet  is  first  slipped  under  the  patient  and 
brought  up  over  the  pillow,  being  tucked  along  the  sides  of  the 
body.  The  frame  is  then  unfolded,  placed  down  over  the 
patient  so  as  to  rest  on  the  mattress,  surrounding  the  patient. 
pillow,  and  rubber  sheet.  The  edges  of  the  sheet  are  then 
drawn  up  over  the  top  rail  and  fastened  to  the  lower  rail  by  its 
rings.  When  complete  it  is  capable  of  holding  about  twenty 
gallons  of  water.  It  may  be  filled  by  either  a  pail  or  hose 
attached  to  a  faucet  and  emptied  by  a  siphon.  This  arrange- 
ment demands  less  moving  of  the  patient  than  any  other  form 
of  bath. 

There  has  recently  been  devised  another  type  of  bed  tub — 
the  Coile  bed  bath  (Plate  VII.').  This  is  a  collapsible  tub  of 
rubber  sheeting,  the  walls  of  which  consist  of  four  superim- 
posed pneumatic  rings.  When  deflated  this  can  be  placed  under 
the  patient  in  the  same  manner  as  the  rubber  sheeting  of  the 
Burr  bed  tub.  It  is  then  inflated  by  means  of  a  large  bicycle 
pump,  and  is  ready  to  receive  the  water.  It  is  emptied  by  a 
sleeve  outlet  as  shown  in  the  illustration. 

Before  being  immersed  in  the  cold  water,  the  head  and  face 
of  the  patient  are  bathed  in  ice  water.  If  the  tub  is  used,  it  is 
necessary  to  provide  an  invalid  ring  for  the  head  and  a  similar 
cushion  or  water  pillow  should  support  the  nates.  If  the 
patient's  skin  is  warm  on  entering  the  bath  and  the  friction  is 
vigorous  and  kept  up  during  the  entire  period  of  immersion, 
there  is  little  danger  of  chilling  or  collapse.  If  at  any  time 
this  should  occur,  the  patient  must  be  immediately  removed  and 
placed  in  a  dry  blanket,  the  surface  being  vigorously  rubbed 
until  the  skin  is  warm  and  reaction  fully  established.  A  com- 
plaint of  chilliness  on  the  part  of  the  patient  may  not  be  an 
indication  for  removal  from  the  bath.  The  appearance  of  goose 
flesh,  however,  necessitates  removal.  The  patient  should  not 
be  allowed  to  remain  in  the  bath  until  the  appearance  of  cyan- 
osis or  any  other  decided  symptom  of  untoward  effects. 

While  the  Brand  bath  seems  to  give  the  best  results  with 
young  vigorous  persons,  where  treatment  can  be  begun  during 


PLATE  V.     Portable  tub  on  wheels  showing  wall  faucets  for  filling  and  floor 
drain  for  emptying  the  tub. 


PLATE  VI.     Portable  tub  with  steel  raising  device. 


TYPHOID  FEVER  183 

the  first  week,  yet  this  method  is  not  applicable  to  those  cases 
which  apply  for  treatment  during:  the  second  or  third  week, 
since  they  have  already  become  so  weakened  that  there  is  not 
sufficient  vitality  to  fully  react  to  so  vigorous  a  means.  The 
Brand  bath  is  also  contraindicated  in  cases  of  much  reduced 
vitality  from  any  other  cause,  and  in  the  very  young  and  in  the 
aged.  In  regard  to  the  use  of  measures  other  than  the  strict 
Brand  bath  Buxbaum l  inclines  to  the  view  that  the  essential 
feature  is  the  obtaining  of  the  reaction  by  suiting  the  treatment 
to  the  needs  of  the  individual  case.  He  says,  "  With  reference 
to  the  special  measures  to  be  employed,  the  desired  result  can 
no  doubt  be  attained  with  the  most  varied  hydriatic  procedures, 
provided  the  thermic  and  mechanical  stimulations  are  graduated 
in  accordance  with  the  indications  of  the  individual  case. 
Hence  there  can  be  no  invariable  and  exclusive  routine." 

With  many  patients  it  is  better  to  employ  a  bath  at  a  higher 
temperature,  the  graduated  bath  of  Ziemssen  or  the  wet  sheet 
pack,  cold  sponging,  compresses,  etc.  A  graduated  bath  be- 
gins at  a  temperature  of  98°,  /.  e.,  3° — 5°  lower  than  the  body 
temperature  or  even  90°  or  95°  F.  and  continues  for  half  an 
hour  or  longer,  during  which  time  the  temperature  is  gradu- 
ally lowered  by  the  addition  of  cold  water,  friction  being  em- 
ployed as  soon  as  the  patient  complains  of  any  chilliness.  The 
temperature  may  be  decreased  to  between  70°  and  80°  F., 
according  to  the  condition  of  the  patient.  This  bath  is  just  as 
effective  as  the  Brand  bath  in  the  reduction  of  the  fever;  in 

• 

fact,  it  is  a  mistake  to  suppose  that  the  colder  the  bath,  the 
greater  is  the  reduction  in  temperature.  This  is  not  the  case. 
A  higher  temperature  for  a  longer  time  may  reduce  the  fever 
just  as  effectively  as  a  lower  temperature  for  a  shorter  time. 
There  is,  however,  this  very  essential  difference,  that  the  stim- 
ulating of  the  body  functions  is  greater  in  proportion  to  the 
degree  of  cold.  With  the  graduated  bath,  as  efficient  and 
thorough  stimulation  is  not  obtained  as  with  the  Brand  bath. 
But  on  the  other  hand,  because  of  this  extreme  stimulation, 
thermogenesis  is  markedly  increased  and,  following  the  Brand 
bath,  the  temperature  rapidly  regains  its  former  height,  so  that 

1    Cohen— System  of  Physiologic  Therapeutics.  Vol.  IX.  p.  134. 


184  TREATMENT  OF  FEVERS 

it  is  necessary  to  repeat  the  bath  very  frequently.  With  a 
graduated  bath  in  which  the  temperature  of  the  water  is  not 
lowered  below  85°  F.,  and  especially  when  it  is  continued  for 
thirty  minutes  to  an  hour,  the  temperature  of  the  patient  does 
not  so  quickly  regain  its  former  height  and  the  bath  need  not 
be  repeated  so  frequently. 

Of  other  methods  the  following"  are  useful  in  special  cases 
or  where  the  ideal  treatment  can  not  be  carried  out: — 

1.  The  Wet  Sheet  Pack  is  perhaps  less  objectionable  to  the 
patient  than  a  cold  bath.     Liebermeister  claims  that  four  wet 
packs  of  ten  minutes  duration  each  are  equivalent  to  a  cold 
bath  of  ten  minutes;  and  Baruch,  that  six  such  packs  are  equiva- 
lent to  a  Brand  bath.     The  sheet   should  be   wrung  from  ice 
water  or  very  cold  water.     It  is  applied  in  the  usual  manner, 
and  after  the  initial  warming,    maintained  at  the  evaporating 
stage,  being  renewed  by  sprinkling  of  more  cold  water  on  the 
sheet.     The  rapidity  of  evaporation  may  be  increased  by  fan- 
ning. 

2.  The  Cold  Towel  Rub  given  with  a  towel  well  filled  with 
very  cold  water  is  an  excellent   substitute   for  the  wet  sheet 
pack.     The  use  of  the  wet  sheet  pack  necessitates  more  or  less 
moving  of  the  patient,   which  is   not  the   case  with   the   cold 
towel  rub.     The  wet  towel  may  be  applied  several  times  to  the 
same  part,  and  even  ice  water  used. 

3.  The  Ice  Rub.     H.  A.  Hare  has  employed  the  ice  rub  with 
good  success.     A  flat  piece  of  ice  is  wrapped  in  thin  linen  or 
gauze,  and  by  rapid  movements  different  parts  of  the  body  are 
gone  over.     He  recommends  this  application  to  the  back  only, 
avoiding  the  extremities.     Others,  however,  utilize  it  as  a  gen- 
eral measure  in  place  of  the  cold  bath. 

4.  Cold  Sponging  and  Cold  Affusions  are  of  decided  advant- 
age in  those  cases  where  the  bath  or  pack  can  not  be  used. 
Cold  affusions  to  the  head  are  of  great  service  in  delirium  and, 
in  fact,  whenever  nervous  symptoms  are  unduly  prominent. 

5.  The  Cold  Abdominal  Compress  is  an  efficient  means  and 
should  be  kept  in  place  between  other  treatments.     The  best 
results  from  this  are   obtained   when    the    Winternitz    coil    is 
placed  over  one  layer  of  the  compress.     The  steady  flow  of  cold 


TYPHOID  FEVER  185 

water  through  the  coil  renders  unnecessary  the  constant 
renewal  of  the  compress,  which  requires  so  much  time  on  the 
part  of  the  nurse.  It  also  avoids  the  shock  from  the  renewal 
which  prevents  the  patient  from  completely  relaxing  for  any 
length  of  time. 

6.  The  Leiter  Coil  or  Cold  Winternitz  Coil  to  the  head  is  a 
very  efficient  means  both  of  preventing  the  rise  of  temperature 
and  alleviating  the  nervous  symptoms.     It  should  be  used  be- 
tween other  treatments.     Cold  applications  to  the  head  decrease 
heat  production  by  acting  upon  the  thermogenic  centers.      The 
ice  bag  or  Leiter  coil  over  the  heart  is  also  serviceable,  espe- 
cially where  the  pulse  is  very  rapid  and  weak. 

7.  The  Cold  Enema,  or  continuous  rectal  irrigation,  is  another 
very  efficient  means.     Since  it  has  been  shown  by  Shuller  that 
the  cold  enema  always  produces  more  or  less  retrostasis,  this 
treatment  may  be  productive  of  harm.     It  should  not  be  used 
where  lung  complications  exist.     Kellogg  mentions  a  case  with 
a  temperature  of  104.2°  F.  in  which  three  large  enemata  at  66°, 
62°,  62°  F.,  given  in  rapid  succession,  reduced  the  temperature 
to  99.2°  within  one  hour.     Such  rapid  and  extreme  reduction  of 
temperature  may  be  dangerous  and  is  hardly  to  be  recommended 
for  general  use.     However,  if  given  at  a  temperature  of  75° — 
85°  and  continued  for  thirty  to  forty-five  minutes,  it  is  a  very 
grateful  and  efficient  means  of  controlling  the  fever. 

The  Daily  Program.  Instead  of  depending  upon  any  one  form 
of  procedure  the  author  prefers  what  may  be  called  a  combina- 
tion method.  It  must  be  admitted  that  "  tubbing  "  every  three 
or  four  hours  entails  more  disturbance  to  the  patient  than  is 
for  his  best  good.2  Nor  is  such  oft  repeated  stimulation  a 
necessity  for  the  sustaining  of  the  circulatory  system,  the  relief 
of  the  nervous  symptoms,  etc.  For  these  reasons  it  is  better  to 
provide  some  means  of  continuous  cooling  such  as  the  cold 
water  coils  to  the  head  and  abdomen  {Plate  VIII.}  regulating 
the  temperature  of  the  water  and  the  rate  of  flow  according  to 
the  necessities  of  the  individual  case.  Rectal  irrigation  is 
another  convenient  method  of  cooling  and  one  which  does  not 


2    The  almost  continuous  attention  together  with  the  extra  nurse  required  at  the  time 
of  the  bath  demand  so  much  help  that  in  some  hospitals  the  method  is  almost  prohibitive. 


186  TREATMENT  OF  FEVERS 

disturb  the  patient.  If  kept  up  long-  at  a  time  the  water  should 
not  be  very  cold  but  rather  tepid  or  cool.  It  has  also  the  ad  van- 
tage of  stimulating-  diuresis  and  the  consequent  elimination  of 
toxines  through  the  aborption  of  water  from  the  bowel. 

These  means  effectually  control  the  temperature.  For 
general  cutaneous  stimulation  the  patient  should  be  g-iven  one 
or  two  tub  baths  daily,  preferably  one  in  the  forenoon  and  one 
in  the  afternoon.  This  may  be  a  modified  cold  rubbing  bath 
or  a  graduated  bath.  Where  tubs  are  not  available,  the  cold 
towel  rub,  the  ice  rub,  or  the  evaporating-  wet  sheet  rub  may 
be  used  for  the  same  purpose.  In  practice  such  a  combination 
of  methods  appears  to  give  the  best  possible  results. 

Hot  Treatment.  In  those  cases  where  chilliness  and  cyan- 
osis are  produced  by  the  cold  bath  and  other  cold  applications, 
or  in  which  this  condition  is  more  or  less  constant,  it  is  neces- 
sary to  thoroughly  warm  the  skin,  bringing-  the  blood  to  the 
surface  and  effectually  reducing  the  extreme  internal  congestion 
before  any  cold  application  can  be  made  with  success.  For 
these  preliminary  hot  treatments  one  may  use  fomentations, 
the  hot  pack,  the  hot  evaporating  sheet  or  hot  s ponging- , 
according  to  the  circumstances  and  indications.  They  may  be 
aided  by  hot  water-drinking.  During-  the  cold  treatment  hot- 
water  bottles  and  spine  bag's  should  be  used  to  keep  the  limbs 
warm  and  prevent  chilling.  The  skin  should  be  red  and  warm 
and  the  patient  feel  warm  before  any  cold  treatments  are  given. 
The  cold  mitten  friction  and  the  cold  towel  rub  are  valuable 
adjuncts  to  the  hot  applications,  since  they  increase  the  warm- 
ing of  the  skin  more  than  they  cool  the  blood.  Cold  applica- 
tions, such  as  ice  bags  and  ice  caps,  should  be  applied  to  the 
head  and  over  the  carotids  whenever  any  decidedly  hot  applica- 
tions are  made.  These  help  to  prevent  any  rise  of  temperature 
while  the  patient  is  being  prepared  by  the  hot  treatment  in 
order  to  react  to  the  succeeding  cold. 

The  Diagnostic  Bath .  Baruch  and  Kellogg  claim  for  the  cold 
bath  a  certain  value  as  a  diagnostic  means  when  employed  dur- 
ing the  first  week  of  the  fever.  Baruch  uses  the  following- 
method:  When  the  rectal  temperature  reaches  103°  F.  and 
other  symptoms  indicate  typhoid  fever,  the  patient  is  tubbed  in 


PLATE  VII.    The  Coile  bed  bath. 


PLATE  VIII.     Author's  method  of  continuous  cooling  in  typhoid  fever. 


TYPHOID  FEVER  187 

water  at  90°  for  ten  minutes,  being  rubbed  continuously.  The 
patient's  temperature  is  taken  one -half  hour  after  the  bath  and 
again  four  hours  after  the  bath.  If,  at  the  termination  of  this 
time,  the  temperature  still  registers  103°  or  over,  the  patient  is 
bathed  in  water  at  85°,  and  the  temperature  recorded  as  before. 
If  it  still  remains  at  103°  or  above,  a  third  bath  at  80°  is  given, 
and  the  fourth  time  at  75°,  employing  friction  with  each. 
Baruch's  experience  with  this  bath  leads  him  to  believe  that,  if 
the  temperature  is  reduced  more  than  two  degrees,  typhoid 
fever  is  improbable;  while,  if  there  is  little  or  no  reduction,  the 
diagnosis  becomes  more  positive. 

Rationale  of  the  Cold  Bath.  The  brunt  of  the  infectious  pro- 
cess and  toxemia  in  typhoid  fever  falls  upon  the  nervous  system, 
the  circulatory  system,  and  the  kidneys. 

1-.  The  Nervoiis  System.  In  fever  it  is  largely  because  of  the 
imperfect  action  and  control  exercised  by  the  nervous  system 
that  many  of  the  body  functions  are  deranged.  It  fails  to  con- 
trol the  heat  mechanism,  the  vasomotors  are  disturbed,  glandu- 
lar activity  is  depreciated.  The  toxemia  is  the  principal  cause 
of  the  derangement  of  the  nerve  centers.  The  congestion 
about  these  centers  which  occurs  in  nearly  all  fevers  only  in- 
creases the  volume  of  toxines  in  the  blood  supplying  them. 
The  nerve  cells  are  benumbed  and  lethargic,  or  they  are  irri- 
table, restless  and  overactive  in  an  irregular  sort  of  way.  The 
high  temperature  adds  to  the  intensity  of  this  state.  It  is  nec- 
essary to  eliminate  the  toxines  and  arouse  the  nervous  system 
from  its  stupor,  stimulating  it  to  a  normal  activity  and  by  tonic 
means,  relieving  its  irritability  so  that  rest  may  be  secured. 

All  these  effects  are  produced  by  the  cold  bath.  The  more 
profound  the  stupor  and  intense  the  delirium,  the  more  marked 
the  relief  experienced.  Quiet  refreshing  sleep  usually  follows 
each  tubbing  or  other  vigorous  cold  treatment.  Subsultus  and 
carphologia  are  relieved.  Headache,  hebetude,  and  apathy  are 
succeeded  by  a  brightening  of  the  mental  powers.  Post-febrile 
insanity  and  mental  weakness  are  less  liable  to  occur  where 
hydrotherapy  is  systematically  employed. 

All  of  the  medicinal  antipyretics  dull  and  stupify  the  nervous 
system.  The  centers  are  not  apprised  of  the  danger  and  so  can 
not  properly  regulate  protective  functions. 


188  TREATMENT  OF  FEVERS 

2.  The  Circulatory  System.  Heart  failure  is  that  to  which  we 
have  been  taught  to  ascribe  all  the  failures  in  the  circulation; 
and  it  is  toward  the  heart  muscle  that  many  medicinal  agents, 
designed  to  act  upon  the  circulation,  are  directed.  This  idea 
has  resulted  in  the  deluging  of  the  system  with  strychnine, 
digitalis,  and  the  like,  and  the  already  overworked  heart  has 
been  compelled  to  do  double  service  to  no  avail.  That  this 
idea  is  almost  wholly  erroneous  has  been  quite  fully  discussed 
in  the  previous  chapter. 

Romberg  and  Passler  have  shown  that  the  chief  danger  to 
the  circulation  in  infectious  diseases  comes  through  paralysis 
and  derangement  of  the  vasomotors,  and  is  not  due  to  any 
damage  to  the  heart  itself.  Passler  further  claims  that  this 
derangement  is  caused  by  loss  of  the  control  exercised  by  the 
vasomotor  centers  in  the  medulla  and  spinal  cord,  the  peripheral 
vasomotor  nerves  and  the  muscles  remaining  intact.  Reflex 
effects  are  still  possible.  The  heart  is  not  at  fault,  but  there  is 
an  absence  of  the  natural  physiologic  resistance  normally  main- 
tained by  the  proper  tone  of  the  blood-vessels,  together  with 
the  loss  of  the  rhythmic  action  of  the  peripheral  heart.  Hare 
very  .aptly  compares  the  heart  and  vasomotors  of  the  circula- 
tory system  respectively  to  a  locomotive  and  the  resistance 
offered  to  its  driving  wheels.  He  says,  "The  locomotive  is 
intended  to  meet  and  stand  any  resistance,  and  if  the  resistance 
is  removed  by  slippery  rails,  the  wheels  fly  around  ineffectually, 
racking  the  machinery  and  destroying  its  usefulness.  From 
the  above,  some  important  diagnostic  and  therapeutic  facts  are 
learned:  (1)  that  a  rapid  pulse  may  be  due  in  no  way  to  a  dis- 
ordered heart,  but  to  vasomotor  relaxation;  (2)  that  the  pro- 
per way  to  treat  this  rapid  pulse  is  to  put  sand  on  the  track  and 
increase  the  resistance,  and  not  to  make  more  steam — or  give 
digitalis — which  only  cause  the  engine,  or  heart,  to  work  away 
oh  slippery  rails  with  more  wear  and  tear,  and  make  no  pro- 
gress." That  this  wear  and  tear  may  be  considerable  and 
result  in  a  weaker  and  more  rapid  pulse,  any  one  may  observe 
who  will,  after  1-60  grain  of  strychnine  has  been  administered 
to  a  typhoid  patient  every  three  hours  for  a  week  or  more,  dis- 
continue the  drug,  recording  the  blood  pressure  before  and  after 


TYPHOID  FEVER  189 

discontinuance  of  the  strychnine'  by  means  of  some  accurate 
blood  pressure  instrument.  Indeed  the  change  for  the  better 
is  so  marked  that  it  can  be  very  readily  appreciated  by  the 
finger  without  other  aid.  In  one  case  that  came  under  the 
author's  observation,  this  was  so  marked  and  appeared  so 
promptly,  that  it  was  observed  at  once  by  both  the  day  and 
the  night  nurses. 

The  cold  friction  bath  meets  the  indication  presented  by  the 
deranged  vasomotors  more  fully  than  is  possible  with  any  other 
means.  It  stimulates  the  blood-vessels  to  normal,  rhythmic 
action  and  relieves  the  heart  of  the  excessive  burden  imposed 
upon  it  by  their  failure.  In  typhoid  fever,  the  blood  is  very 
much  reduced  in  quality.  The  red  cells  and  hemoglobin  are 
decreased,  the  latter  to  a  greater  extent  than  the  former,  espe- 
cially during  convalescence.  There  is  a  decided  leucopenia, 
the  white  cells  being  decreased  in  number  one-third,  or  even 
more  than  one-half.  The  blood  is  laden  with  acid  poisons  and 
is,  therefore,  reduced  in  alkalinity  (Bireger).  The  amount  of 
toxic  extractives  in  the  blood  has  been  shown  by  Robin  to  be 
doubled  or  trebled  in  case  of  fevers.  We  have  already  quite 
extensively  discussed  the  effect  of  the  cold  bath  on  the  com- 
position of  the  blood.  Suffice  it  to  say  that  observations  made 
by  Strasser,  Breitenstein,  Baruch  and  others  prove  conclusively 
that,  in  typhoid  fever,  every  constituent  of  the  blood  is  favor- 
ably influenced  by  the  cold  friction.  The  red  cells  in  the  peri- 
pheral circulation  are  greatly  increased,  the  white  cells  in- 
creased as  high  as  two  or  threefold,  the  alkalinity  is  restored 
and  acid  products  decreased.  Because  of  these,  normal  nutri- 
trive  changes  proceed  more  promptly. 

3.  The  Kidneys.  Elimination  in  febrile  conditions  is  very 
defective.  The  quantity  of  urine  is  decreased  and,  while  there 
may  be  an  increase  in  the  solid  constituents,  it  is  still  quite 
instifficient  to  prevent  the  accumulation  of  toxic  wastes  in  the 
blood  and  tissues.  During  convalescence,  the  solids  of  the  urine 
increase  from  10  to  20  per  cent,  or  more,  over  the  amount 
excreted  during  the  febrile  period.  The  poisonous  wastes  are 
more  insoluble  than  those  of  little  or  no  toxicity  and  so  require 
a  larger  quantity  of  the  solvent — water — for  their  efficient  elim- 
ination. 


190  TREATMENT  OF  FEVERS 

The  cold  bath  greatly  increases  diuresis.  The  quantity  of 
solvent  is  increased,  thus  increasing  the  toxines  eliminated. 
But  this  alone,  does  not  account  for  the  great  increase  in  the 
toxicity  of  the  urine  under  the  bath  treatment.  While  the 
poisons  of  the  urine  in  typhoid  fever  are  double  the  normal 
amount,  Roque  and  Weil  found  them  increased  five  times  after 
the  cold  bath.  Bouchard  also  found  the  toxic  co-efficient  of  the 
urine  greatly  increased  by  the  cold  bath.  Robin  in  one  case 
found  the  urea  increased  to  20  per  cent.  On  the  contrary, 
antipyretic  drugs  diminish  the  excretion  of  urea  and  nitrogen. 
The  liver  in  those  cases  dying  after  treatment  with  antipyrin, 
is  said  to  be  heavier  than  the  liver  of  those  dying  after  the  cold 
bath  treatment.  These  drugs  produce  granular  and  fatty 
changes  in  the  liver  and  kidneys. 

The  respiratory  elimination  of  COz  and  intake  of  oxygen  are 
decreased  in  fevers,  the  amount  of  the  decrease  being  in 
inverse  proportion  to  the  severity  of  the  fever.  This  is  due,  of 
course,  to  the  lessened  capacity  of  the  body  tissues  to  utilize 
oxygen.  Both  oxygen  absorption  and  carbon  dioxide  elimina- 
tion are  enhanced  by  the  cold  bath.  Robin  found  the  increase 
approximating  20  to  30  per  cent  above  the  usual  amounts  in 
typhoid  fever.  That  all  these  results  are  beneficial  needs  no 
argument.  There  is  no  organ,  tissue,  or  function  not  favor- 
ably influenced  by  the  hydriatic  treatment  of  typhoid  fever. 
Because  of  the  maintenance  of  the  vital  resistance  and  the 
elimination  of  toxines  during  the  febrile  period,  convalescence- 
is  much  shortened  when  cold  baths  have  been  used. 

Contraindications  and  Treatment  of  Complications 

Pneumonia.  The  cold  bath  is  contraindicated  in  pneumonia 
of  the  lobar  type.  The  case  should  be  treated  as  far  as  possible 
as  simple  pneumonia  alone  would  be  treated.  Fomentations, 
cold  compresses,  alternate  hot  and  cold  applications,  the  ice 
pack  to  the  chest,  and  such  means  are  applicable  where  the 
pneumonia  arises  as  a  complication  and  may  be  used  in  much 
the  same  manner  as  is  ordinary  pneumonia.  Special  attention 
must  be  given  to  the  extremities.  They  should  be  kept  warm 
and  the  circulation  active.  The  cold  mitten  friction,  wet  towel 


TYPHOID  FEVER  191 

rub,  sponging-,  and  affusions  are  serviceable  in  place  of  the  bath. 
Hypostatic  pneumonia  may  be  treated  by  alternate  hot  and  cold 
applications,  cold  affusions,  or  ablutions  to  the  back.  The 
warm  bath  graduated  down  to  90°  F.  may  be  used. 

Pleurisy.  This  condition  absolutely  contraindicates  the  use 
of  the  cold  bath.  No  cold  whatever  should  be  applied  to  the 
chest  over  the  inflamed  area  until  the  acute  stage  is  passed, 
that  is,  for  two  or  three  days.  However,  the  cold  towel  rub 
and  cold  mitten  friction,  sponging,  etc.,  should  be  kept  upas 
usual,  avoiding  only  the  skin  surface  over  the  inflamed  pleura 
for  the  first  two  or  three  days.  If  the  cold  baths  are  continued 
or  large  cold  compresses  used  to  the  abdomen,  a  mild  pleurisy 
may  become  so  fixed  as  to  require  months  for  the  eradication  of 
the  chronic  inflammation. 

Nephritis.  Contrary  to  what  might  be  expected,  the  use  of  the 
cold  bath  is  not  wholly  contraindicated  in  this  condition.  Mild 
cases  of  nephritis  improve  under  the  Brand  bath.  If  the 
nephritis  is  severe,  the  graduated  bath  may  be  substituted. 
Yogi's  experience  demonstrates  that  nephritis  is  less  common 
in  those  treated  by  the  Brand  bath,  and  also  that  the  mortality 
is  less  in  those  having  nephritis.  Both  the  urine  and  urea 
increase  in  quantity  and  the  albumen  decreases  under  the 
effects  of  the  cold  bath.  Venous  congestion  of  the  kidneys  is 
conducive  to  nephritis,  albuminuria,  and  the  formation  of  casts. 
This  condition  is  relieved  by  the  stimulation  of  the  circulation 
and  derivation  secured  by  the  cold  friction. 

Hemorrhage.  The  cold  bath  must  be  discontinued  as  soon  as 
this  condition  becomes  apparent,  principally  because  of  the  rest 
needed.  The  limbs  should  be  kept  warm  and  some  sort  of  cold 
application  placed  over  the  abdomen.  We  believe  the  most 
satisfactory  measure  is  the  Winternitz  coil.  This  does  away 
with  the  shock  occasioned  by  the  renewing  of  cold  compresses, 
and  the  temperature  can  be  more  accurately  gauged  and  more 
perfectly  controlled  than  with  the  ice  bag.  After  the  recovery 
from  the  hemorrhage,  it  is  best  to  permanently  discard  the  use 
of  the  bath,  substituting  sponging,  affusions,  the  cold  towel 
rub,  etc. 

Perforation.     Here,  as  in  hemorrhage,  the  cold  bath  must  be 


19g  TREATMENT  OF  FEVERS 

discontinued,  the  patient  being  treated  by  rest  and  means  used 
to  control  the  shock,  so  that  operation  may  be  done  as  soon  as 
possible.  If  peritonitis  supervenes,  it  becomes  the  chief 
objective  point. 

The  reduction  in  mortality  from  typhoid  since  the  introduc- 
tion of  the  cold  bath  has  not  been  due  to  reduction  in  the  mor- 
tality from  hemorrhage  and  perforation.  According  to  Hare 
the  mortality  from  these  causes  before  and  after  the  introduc- 
tion of  the  Brand  bath  is  practically  the  same.8  The  mortality 
from  all  other  causes  was  much  less,  dropping  from  9.7  to  3.4 
per  cent  and,  in  spite  of  no  change  from  the  above  mentioned 
conditions,  there  was  a  total  decrease  in  mortality  of  nearly  50 
per  cent. 

Menstruation.  The  menses  frequently  cease  during  severe 
febrile  conditions,  but  cases  in  which  it  has  continued  have 
been  successfully  treated  by  cold  baths;  and  under  this  treat- 
ment, cases  of  pregnancy,  complicated  by  typhoid,  have  been 
carried  to  a  successful  issue. 

Tympanites.  The  cold  bath  greatly  relieves  this  condition. 
The  continuous  use  of  the  ice  water  coil ,  interrupted  every  hour 
or  two  by  fomentations,  gives  great  relief.  The  asafoetida  or 
turpentine  enema  should  not  be  omitted  where  more  energetic 
means  are  needed.  The  plain  cold  enema  or  continuous  rectal 
irrigation  are  also  very  useful  in  tympanites. 

Mortality  and  Statistics 

Modern  methods  in  the  rational  treatment  of  disease  have 
accomplished  few  more  striking  changes  than  those  accompany- 
ing the  hydriatic  treatment  of  typhoid  fever.  The  reduction  in 
mortality  compares  quite  favorably  with  the  lessened  fatality  in 
small  pox  since  the  introduction  of  vaccination,  and  that  of 
diphtheria  since  the  employment  of  antitoxine.  The  prophy- 
.lactic  use  of  antityphoid  vaccination  has  proven  an  almost  un- 
failing means  of  preventing  large  epidemics  such  as  occur  in 
army  practice  and  even  in  hospitals.  It  is  to  be  hoped  that  it 
will  also  show  itself  of  material  help  in  treatment  in  lessening 
the  severity  of  the  attack. 

3    Brisbane  Hospital.  Queensland.  1882—1896. 


TYPHOID  FEVER  19S 

Under  the  ordinary  expectant  plan  with  administration  of 
medicinal  antipyretics,  statistics  from  Germany  show,  among 
11, 124  cases,  a  mortality  of  21.7  per  cent.  In  another  collec- 
tion of  27,051  cases,  there  was  a  mortality  of  17.45  per  cent. 
In  still  another  collection  of  80,140  cases.,  there  was  a  mortality 
of  19.23  per  cent. 

In  one  divison  of  the  German  army,  during  seventeen  years 
among  1970  cases,  the  mortality  was  26.3  per  cent.  In  the 
English  army  for  six  years,  ending-  with  1877,  there  was  a 
mortality  from  typhoid  of  32  per  cent.  In  recent  years,  Dela- 
field  shows  a  mortality  of  26  per  cent  from  the  New  York  hos- 
pitals. And  throughout  American  cities,  the  mortality  from 
typhoid  fever  is  claimed  to  be  from  25  to  40  per  cent.  In  the 
typhoid  wards  of  the  Johns  Hopkins  Hospital,  during-  the  first  ten 
years,  nine  of  which  is  since  the  introduction  of  hydrotherapy, 
Osier  reports  among-  829  cases,  a  mortality  of  7.5  per  cent. 
During  the  first  year  of  this  time,  the  cases  were  treated  by  the 
ordinary  expectant  plan  and,  moreover,  this  series  includes  all 
cases  admitted,  those  dying  within  one  or  two  days  and  those 
diagnosed  at  autopsy.  From  the  Brisbane  Hospital,  Hare  re- 
ports a  typhoid  mortality  of  14.8  per  cent  previous  to  the  intro- 
duction of  hydrotherapy  and  7.5  per  cent  since  its  employment. 

In  1887  Brand  gathered  statistics  of  19,017  cases,  showing- 
under  all  forms  of  hydriatic  treatment,  a  reduction  in  mortality 
from  21.8  per  cent  to  7.8  per  cent.  In  another  series  of  cases 
collected  by  Brand  and  enlarg-ed  by  Baruch,  in  which  the  strict 
cold  bath  treatment  was  used,  Baruch  claims  a  reduction  of 
mortality  to  3.9  per  cent. 

In  the  divison  of  the  German  army  above  referred  to,  the 
mortality  under  the  strict  Brand  system  was  reduced  from  26.3 
per  cent  to  4.3  per  cent.  Baruch  further  claims  that  among- 
1223  cases  treated  only  by  apostles  of  the  Brand  system,  there 
was  a  reduction  in  mortality  to  1  per  cent  (twelve  cases)  and 
that  "not  one  of  these  twelve  deaths  occurred  in  any  case  that  came 
under  treatment  before  the  fifth  day." 

Contrary  to  what  might  be  expected,  the  mortality  is  less  in 
private  practice  than  in  hospitals.  This  is  doubtless  because 
the  cases  come  under  observation  at  once  and  can  be  treated 

13 


194  TREATMENT  OF  FEVERS 

from  the  beginning-.  The  same  is  true  of  army  and  navy  hos- 
pitals where  all  indispositions  are  at  once  investigated  by  the 
medical  officer. 

The  statistics  gathered  by  Baruch4  relative  to  the  mortality 
from  typhoid  fever  under  the  varying  methods  are  the  most  ex- 
tensive on  record.  The  reduction  in  mortality  seems  to  depend 
upon  (l)  the  strict  employment  of  hydrotherapy  by  the  cold 
bath  method  where  cases  come  under  observation  before  the  fifth 
day;  (2)  the  discarding  of  all  medicinal  antipyretics;  (3)  judi- 
cious employment  of  various  forms  of  hydrotherapy  where  cases 
can  not  be  treated  from  the  beginning;  (4)  private  practice. 

MALARIA 

Since  this  disease  is  of  an  "infectious"  nature,  being  clue  to 
the  malarial  plasmodium,  treatment  must  be  directed  toward 
the  destruction  of  the  parasite.  This  may  be  accomplished  in 
either  of  two  ways,  — first,  by  the  toxic  action  of  quinine;  and 
second,  by  the  phagocy tic  action  of  the  white  blood  cell .  That 
quinine  does  kill  the  parasite  and  thereby  check  the  disease,  no 
one  can  dispute.  But  that  it  also  fails  of  effecting  a  cure  in  by  far 
the  larger  number  of  chronic  cases  and  many  of  the  acute 
cases,  is  also  indisputable,  being  witnessed  by  the  experience  of 
all  practitioners  whose  practice  brings  them  in  contact  with  this 
disease.  The  last  word  concerning  malaria  has  yet  to  be 
spoken.  It  would  seem  that  giving  quinine  in  an  acute  case 
which  has  not  previously  been  taking  a  course  of  quinine,  if  so 
adminstered  that  there  is  a  maximum  dose  in  the  blood  just  pre- 
vious to  sporulation  which  produces  the  chill,  stopping  there, 
no  more  being  given  until  the  proper  time  before  the  next  ex- 
pected paroxysm,  is  productive  of  good  results;  however,  it  often 
fails  in  the  estivo-autumnal  type,  since  it  is  uncertain  just  when 
•a  paroxysm  may  be  expected,  sporulation  being  irregular  so  that 
the  above  program  can  not  always  be  carried  out  successfully. 
It  has  also  been  shown  that  quinine  fails  of  its  best  results  or 
fails  altogether  where  it  has  previously  been  administered  for 
some  time  as  a  prophylactic,  or  in  the  treatment  of  other  attacks. 

4    Baruch— Principles  and  Practice  of  Hydrotherapy.  p.  202. 


MALARIA  195 

The  following  experience 5  related  by  Dr.  E.  R.  Stitt,  a  United 
States  Navy  surgeon ,  is  worthy  of  careful  thought: — 

"  While  in  camp  along  the  canal  route,  we  had  a  few  cases  of 
malaria.  These  were  immediately  treated  with  large  doses  of 
quinine,  and  without  exception  they  responded  promptly  and 
satisfactorily  to  such  treatment.  The  only  member  of  the  party 
who  insisted  on  taking  quinine  prophylactically  was  Colonel 
Ludlow,  the  head  of  the  commission;  and  strange  to  say,  he 
was  the  only  one  who  had  malaria  on  the  trip  home." 

'  To  those  who  have  thought  of  quinine  prophylaxis  as  a  true 
preventive,  the  following  instance  is  instructive: — 

"  On  May  20,  1906,  a  battalion  of  marines,  numbering  398, 
was  organized  at  Philadelphia.  Seventy-five  per  cent  of  the 
force  was  made  up  of  recent  recruits  from  the  Middle  West. 

"Leaving  Philadelphia  May  21,  Colon  was  reached  May  28. 
On  June  4  the  battalion  vvas  disembarked  at  Colon  and  stationed 
for  a  time  at  Camp  Elliott,  which  is  situated  about  twenty-five 
miles  from  Colon  and  which  was  comparatively  free  from  mos- 
quitoes. Later  on,  three  companies  were  stationed  at  Camp 
Reed,  five  miles  from  Panama,  at  which  place  mosquitoes  were 
numerous  and  troublesome. 

"  On  July  6,  after  a  service  of  practically  one  month  on  the 
Isthmus,  the  marines  returned  to  the  ship  (U.  S.  S.  Columbia). 
During  the  month's  encampment,  9  grains  of  quinine  had  been 
served  out  daily  as  a  prophylactic.  In  addition,  such  measures 
as  head-nets  for  those  on  night  sentinal  duty  and  inspection  of 
mosquito  nets  about  the  men  sleeping  in  tents  had  been  in  force. 
There  was  very  little  malaria  reported  from  these  men  while  on 
the  Isthmus. 

The  ship  sailed  from  Colon  on  the  night  of  July  7.  On  the 
first  day  out,  twenty  cases  of  malaria  were  admitted  to  the  sick 
list,  the  next  day  fifty-three,  and  the  third  day  forty-five.  'In 
consequence  of  what  appeared  to  the  medical  officer  to  be  uni- 
versal infection  among  the  men,  10  grains  daily  of  quinine  were 
administered  to  every  one  as  a  prophylactic.  Notwithstanding 
this  almost  curative  dosage  of  quinine,  the  condition  of  the  men 
was  such  when  the  ship  arrived  at  San  Jaun,  July  13,  that  it 

5    Journal  of  American  Medical  Association.  May  23,  1908.  p.  1683. 


196  TREATMENT  OF  FEVERS 

was  deemed  necessary  to  get  the  men  out  of  the  tropics,  as  sev- 
eral cases  of  a  pernicious  type  and  two  of  blackwater  fever  had 
appeared.  Accordingly  the  ship  sailed  for  Boston  July  16. 

"Notwithstanding-  the  prophylactic  use  of  quinine,  under 
military  observation,  for  those  who  were  not  cinchonized,  there 
were  215  acute  malarial  paroxysms  among1  298  men  during1  the 
five  days'  trip  from  San  Juan  to  Boston.  About  100  men  of  the 
original  398  had  been  transferred  to  other  ships  and  stations 
prior  to  the  sailing-  of  the  Columbia  for  Boston.  The  character 
of  the  paroxysms  was  atypical — there  was  no  frank  chill.  The 
men  would  feel  fairly  well  until  shortly  before  an  attack,  they 
would  then  complain  of  chilliness  and  weakness  and  either  Ik- 
down  or  fall  down  in  a  heap  on  deck.  Passed  Assistant  Surgeon 
Butler,  U.  S.  N.,  states  in  a  report,  that  when  the  men  arrived 
at  Boston  so  many  were  anemic  and  weak  that  they  were  unfit  to 
return  to  the  tropics.  Doctor  Butler  also  noted  the  fact  that 
these  cases  did  not  seem  to  respond  at  all  satisfactorily  to  qui- 
nine even  when  given  hypodermatically.  Before  the  cases  be- 
came so  numerous,  blood  examinations  were  made  and  the  f  jrm 
of  malaria  was  considered  to  be  chiefly  tertian.  The  clinical 
features,  however,  would  indicate  that  there  was  estivo-autumnal 
infection  in  many  of  the  cases. 

"In  considering  the  experience  of  these  marines  who  were 
given  prophylactic,  I  might  even  say  curative,  doses  of  quinine 
during  a  period  just  exceeding  a  month,  and  when  this  was  dis- 
continued during  the  days  of  July  7,  8,  9,  and  10,  showed  an 
extensive  malarial  morbidity,  the  question  naturally  presents 
itself  as  to  the  explanation  of  this.  Furthermore,  we  must  noto 
the  fact  that  resumption  of  quinine  prophylaxis  at  this  time  in 
those  not  cinchonized  apparently  had  little  effect  in  checking 
the  outbreak,  and  that  when  quinine  was  adminstered  in  cura- 
tive doses,  at  times  hypodermatically,  it  did  not  seem  to  con- 
trol infection  as  is  usual.  It  is  common  experience  that  mal- 
aria responds  readily  and  promptly  to  quinine  properly  admin- 
istered. I  can  not  but  believe  that  malarial  parasites  may  de- 
velop a  reistance  to  quinine. 

"  Browning,  reporting  recent  work  in  Ehrlich's  laboratory, 
states  that  when  mice  infected  with  trypanosomes  were  not  given 


MALARIA  197 

sufficent  doses  to  destroy  the  flagellates,  these  protozoa  devel- 
oped a  resistance  to  the  therapeutic  agent  during  the  time  their 
development  was  held  in  abeyance.  A  most  startling  discovery 
was,  too,  that  these  trypanosomes  retained  their  chemo-resist- 
ance  through  numberless  generations.  After  passage  during  a 
period  of  fourteen  months  through  144  mice,  these  last  genera- 
tions of  trypanosomes  still  retained  their  immunity  to  the  excit- 
ing drug.  Browning  experimented  with  atoxyl,  parafuchsin, 
and  trypan  blue.  Experiments  with  paramecium  have  also 
shown  that  these  ciliates  may  develop  marked  resistance  to 
agents  primarily  toxic  to  them." 

While  not  commonly  met  with  in  subtropical  countries,  it  is 
possible  for  the  body  to  acquire  immunity  to  malaria.  This  is 
manifest  in  numerous  dark-skinned  races.  In  regard  to  the 
action  of  quinine  in  preventing  the  acquisition  of  immunity,  the 
following  from  H.  T.  Brooks6  is  particularly  significant:  "  For 
acquisition  of  this  immunity,  however,  it  is  necessary  that  the  nat- 
ural course  of  the  disease  remain  unintermipted  by  administration 
of  quinine,  in  order  that  the  natural  immunizing  processes  may 
completely  take  place  in  the  blood.  R.  Koch  has  demonstrated 
that  in  all  localities  where  the  adult  natives  are,  so  to  speak, 
immune  to  malaria,  the  children  invariably  are  attacked  by  the 
disease.  They  invariably  pass  through  febrile  attacks  and 
always  have  malarial  parasites  in  the  blood,  often  abundantly. 
The  natives  know  neither  quinine  nor  any  similarly  acting  drug 
for  controlling  the  malady.  They  allow  it  to  take  its  course, 
and  numerous  children  die  of  the  disease;  those  who  survive, 
however,  are  immune  for  the  rest  of  their  lives,  that  is,  in  spite 
of  the  sting  of  infected  anopheles,  they  no  longer  offer  a  good 
soil  for  the  malarial  plasmodia,  and  hence  the  latter  are  incap- 
able of  development  in  their  blood." 

The  experiments  of  Bass  and  Johns  '  in  the  cultivation  of 
malarial  plasmodia  in  vitro  have  brought  out  some  very  inter- 
esting and  important  facts  relative  to  the  mechanism  of  protec- 
tion in  malarial  infection.  From  the  report  of  this  work  we 
quote  the  following: — 

6  General  and  Special  Pathology,  1912,  p.  411. 

7  The  Cultivation  of  Malarial  Plasmodia   (plasmodium.vivax  and  plasmodium  falci- 
parum)  in  Vitro,  Journal  of  Experimental  Medicine,  Vol.  XVI,  No.  4,  1912.  • 


198  TREATMENT  OF  FEVERS 

' '  The  parasites  have  been  grown  in  the  presence  of  red  blood 
cells  only.  We  have  not  seen  any  evidence  that  they  can  be 
grown  independently  of  these  cells.  As  already  stated,  they 
can  not  live  for  even  a  few  minutes  free  in  the  serum.  Serum 
inactivated  of  its  complement  is  less  destructive,  but  the  plas- 
modia  can  not  live  in  it  for  any  considerable  length  of  time. 
When  cultures  are  prepared  according  to  the  technique  described 
for  the  cultivation  of  one  generation  only,  the  leucocytes  mi- 
grate more  or  less  toward  the  surface  and  soon  become  actually 
concentrated  in  the  layer  in  which  the  parasites  grow.  Leuco- 
cytes do  not  phagocytize  parasites  as  long  as  they  are  inside  of 
the  red  blood  cells,  but  as  soon  as  segmentation  takes  p'acc 
and  the  capsule  of  the  red  cells  ruptures,  liberating  mcrozoites, 
the  latter  are  promptly  engulfed.  In  fact,  it  is  not  uncommon 
to  see  a  leucocyte  that  has  phagocytized  one  or  more  full 
rosettes.  This  probably  occurs  after  the  parasite  has  digested 
the  capsule  or  otherwise  made  a  small  opening  through  it, 
whereby  it  is  converted  into  a  foreign  body  which  the  leucocytes 
try  to  remove.  Dead  parasites  in  red  blood  cells  are  also 
phagocytized,  providing  the  enveloping  cell  substance  is  suffi- 
ciently permeable.  Parasites  phagocytized  are  soon  killed  and 
finally  digested.  As  a  result  of  this  phagocytosis,  few  if  any 
parasites  in  such  a  culture  escape  to  develop  a  second  genera- 
tion." "If  more  than  one  generation  of  plasmodia  is  to  be 
cultivated,  it  is  necessary  to  remove  the  leucocytes  when  the 
culture  is  made  in  order  to  avoid  destruction  of  the  parasites 
by  them  at  the  time' of  segmentation." 

It  is  thus  amply  demonstrated  that  the  phagocytes  and  the 
protective  substances  of  the  serum  are  highly  destructive  to  the 
parasites.  For  the  natural  protection  of  the  body  against 
malarial  parasites  it  is,  therefore,  necessary  to  increase  the 
number  and  activity  of  the  phagocytes  and  stimulate  the  pro- 
duction of  chemical  lysins. 

It  is  a  well  known  fact  that  while  quinine  kills  the  plasmo- 
dium,  it  also  kills  the  white  blood  cell.  In  fact  the  two  are 
quite  similar  bits  of  protoplasm  manifesting  quite  similar  activi- 
ties. The  white  blood  cells  acquire  little  or  no  resistance  to  it. 
If  they  are  not  destroyed,  they  are  for  the  time-being  paralyzed 


MALARIA  199 

and  phagocytosis  suppressed.  We  previously  called  attention 
to  the  fact  that  10  grains  in  the  blood  of  a  patient  weighing  130 
pounds  constitutes  nearly  double  a  toxic  dose  for  the  phago- 
cytes. In  these  facts  lies  the  explanation  of  the  failure  of 
quinine  to  cure  chronic  cases.  The  parasite  becomes  accus- 
tomed to  the  poison,  or  as  we  might  say,  acclimated  to  its 
unfavorable  environment,  while  the  white  blood  cells  succumb 
to  the  toxic  action.  The  parasite  has  then  nothing  to  oppose 
its  action  and  it  multiplies  and  thrives  at  the  expense  of  the 
red  blood  cells.  The  latter  are  broken  up  and  hemoglobinemia 
and  hemoglobinuria  result.  This  breaking  up  is  increased  by 
the  action  of  the  quinine  itself,  and  so  the  case  goes  on  from 
bad  to  worse.  In  fact,  it  is  claimed  by  many  southern  practi- 
tioners that  blackwater  fever — the  hemoglobinuric  form  of 
chronic  malaria — is  due  to  quinine  and  not  to 'the  parasite. 

In  regard  to  the  relation  of  quinine  to  hemoglobinuria  we 
again  quote  from  H.  T.  Brooks:8  "  In  certain  regions,  such  as 
West  and  East  Africa  (but  not  in  India),  if  quinine  is  taken 
prophylactically  in  large  doses  for  a  long  time — at  least  half  a 
year — destruction  of  the  red  blood  cells  may  occur  so  rapidly 
after  onset  of  this  severest  form  of  malaria  (estivo-antumnal) 
that  the  liver  is  no  longer  able  to  transform  the  large  amount  of 
hemoglobin  liberated  in  the  blood  into  bile-coloring  matter; 
therefore,  a  greater  part  of  it  is  excreted  through  the  kidneys, 
producing  hemoglobinuria.  ...  As  a  result  of  the  enormous 
solution  of  the  red  blood  cells,  the  renal  tubules,  on  further 
course  of  the  disease,  become  completely  occluded  and  no  urine 
can  be  secreted.  Autointoxication  of  the  body,  chills,  vomiting, 
and  diarrhoea  set  in  and  death  occurs." 

We  must,  therefore,  in  these  cases  abandon  the  use  of  quinine 
and  search  for  some  means  of  increasing  the  number  of  the 
leucocytes  and  enhancing  their  phagocytic  activity.  The  reac- 
tion to  cold  applications  when  combined  with  mechanical  means 
is  that  which  best  produces  this  result.  Some  enthusiastic 
hydriatists  have  endeavored  to  combat  the  disease  by  the  use 
of  hot  sweating  measures  applied  as  soon  as  there  are  any 
indications  of  the  beginning  of  the  chill  and  continued  until 

8    General  and  Special  Pathology,  1912,  p.  407. 


200  TREATMENT  OF  FEVERS 

sweating-  is  well  established,  little  attention  being-  given  to  the 
frequent  and  systematic  use  of  cold  frictions,  affusions,  douches, 
etc.  The  sweating  combats  nothing  but  the  effects  of  the  chill; 
it  in  no  way  removes  the  cause,  augments  the  vital  resistance, 
or  restores  the  blood  to  that  condition  in  which  it  is  best  able 
to  combat  infection.  On  the  contrary,  if  at  all  prolonged,  the 
resistance  is  lessened.  Quinine,  the  malarial  toxine,  and  long 
hot  treatments,  all  lessen  the  number  of  leucocytes,  driving- 
them  into  the  viscera  where  they  stagnate.9 

Nearly  all  who  employ  hydrotherapy  in  any  regular  manner 
have  witnessed  the  beneficial  results  that  may  be  obtained  in 
the  treatment  of  chronic  malaria.  The  general  plan  to  be  fol- 
lowed is  that  of  some  systematic  regime  of  tonic  measures,  care- 
fully graduated  and  suited  to  the  needs  of  the  individual  case. 
We  have  seen  chronic  cases  in  which  30  grains  of  quinine 
administered  daily  had  failed  to  check  the  fever,  brought  to  a 
successful  issue  by  the  regular  use  of  the  cold  mitten  friction 
and  alternate  hot  and  cold  applications. 

The  plan  followed  by  Fleury  in  the  treatment  of  over  100 
cases  of  malaria  in  the  German  colonies  in  Africa  is  worthy  of 
imitation.  One  or  two  hours  previous  to  the  expected  par- 
oxysm, he  administered  douches  at  55° — 60°  F.  From  his 
experience  there,  he  concludes  that  in  chronic  cases  of  inter- 
mittent malarial  fever  with  cachexia,  anemia,  relapses,  etc., 
cold  douches  are  always  to  be  preferred  to  quinine,  also  that  in 
acute  intermittent  fever  it  may  be  used  instead  of  quinine. 
These  conclusions  were  confirmed  at  the  military  hospital  at 
Brussels  by  the  investigations  of  a  Royal  Belgian  Commission. 
Strasser,  Fisher,  Fodor,  and  others  have  reported  cases  suc- 
cessfully treated  by  cold  applications.  H.  F.  Rand,  formerly 
professor  of  physiologic  therapeutics  in  the  University  of  Colo- 
rado, has  successfully  treated  cases  by  the  use  of  the  cold 
mitten  friction,  cold  towel  rub,  and  the  cold  half  bath  with 
friction.  He  begins  a  number  of  hours  before  the  chill  is  due. 
He  reports  a  case  of  chronic  malaria  in  which  no  chill  appeared 

"In  the  first  attack  absolute  and  relative  leukopenia  is  observed  which  is  due  to  the 

;tion  of  the  white  cells  in  the  liver  and  spleen,  to  the  destruction  of  the  phagocytes, 

;"„      i'!Jv7C       ?S  a>  to  leslons  of  tne  blood-making  organs."— Edward  s  Practice  of  Medi- 

(lilt*,  1VU/,  p.  llo. 


MALARIA 


201 


after  the  beginning  of  the  treatment.     At  the  end  of  a  week 
the  blood  was  free  from  plasmodia. 

As  in  other  fevers,  the  rationale  of  these  measures  is  not 
difficult  of  explanation.  It  has  been  shown  by  Maragliano  10  that 
contraction  of  the  surface  vessels  in  malaria  begins  two  hours 
before  the  temperature  begins  to  rise  and  about  three  hours 
before  the  paroxysm  (Fig.  49.}.  The  skin  vessels  continue  to 


105.8 


102.2 


100.4 


98.6 


Fig.  49.  Chart  showing  the  causative  relation  of  peripheral  vasocon- 
striction  to  the  fever  and  chill  in  quotidian  malaria.  P — state  of  peri- 
pheral blood-vessels  as  shown  by  the  plethysmograph,  T — tempera- 
ture. (Maragliano.) 

contract,  and  the  fever  reaches  the  highest  point  wrhen  the 
vessels  are  in  a  state  of  maximum  constriction.  During  the 
sweating  stage  the  vessels  dilate,  and  when  maximum  dilata- 
tion is  reached  the  temperature  returns  to  normal.  During  the 
two  hours  referred  to,  the  constriction  of  the  skin  vessels  and 
anemia  of  the  skin  becomes  well  "  fixed,"  so  that  a  severe  pro- 
longed chill  is  provided  for.  At  the  same  time  there  is '  an 
enormous  retention  of  heat  due  to  the  failure  in  heat  elimina- 

10    Plethysmograph  experiment— quoted  from  Buxbaum— Lehrbuch  der  Hydrothera- 
pie,  1903. 


got  TREATMENT  OF  FEVERS 

tion.  The  internal  congestion  is  intense.  Under  these  circum- 
stances the  cold  percussion  or  friction  has  a  double  effect. 
First,  by  the  production  of  circulatory  reaction  the  spasm  of  the 
peripheral  vessels  is  relieved  and  the  internal  congestion  gives 
way  because  of  an  equalization  of  the  circulation.  The  chill  is 
thus  aborted.  Second,  the  leucocytes  are  "mobilized"  and 
phagocytosis  encouraged.  In  malaria  the  leucocytes  forsake 
the  peripheral  circulation  and  accumulate  in  the  viscera,  espe- 
cially the  spleen.  Experiments  with  the  oncometer  show  that 
cold  applications  cause  contraction  of  this  organ.  This  action, 
together  with  the  stimulation  of  the  vasomotors  of  the  peri- 
pheral vessels,  serves  to  distribute  and  energize  this  vast  army 
of  phagocytes.  Besides  the  mobilization  of  the  phagocytes, 
visceral  globular  stasis  of  the  red  cells  is  prevented.  It  is 
believed  by  Bass  and  Johns  that  for  malarial  parasites  to  pass 
from  red  cell  to  red  cell,  these  must  be  in  actual  contact  with 
each  other  in  order  that  the  parasite  escape  the  destructive 
action  of  the  serum  in  which  they  can  not  live  for  even  a  few 
minutes.  Their  conclusion  is  this:  "  From  our  observations 
of  malarial  plasmodia  growing  in  vitro,  we  believe  that  in  vivo 
they  can  pass  from  cell  to  cell  only  when  a  cell  is  in  direct  con- 
tact with  another  cell  containing  a  segmenting  parasite,  and  then 
only  when  the  opening  for  the  exit  of  merozoites  occurs  oppo- 
site the  cell  to  be  infected." 

If  this  conclusion  be  true,  such  reinfection  of  red  cells  would 
be  greatly  favored  by  the  globular  stasis  which  occurs  at  the 
time  of  the  chill.  On  the  other  hand,  it  would  be  very  greatly 
hindered  by  an  active  visceral  and  peripheral  circulation  in 
which  condition  the  majority  of  the  young  parasites  would  for 
a  long  time  be  exposed  to  the  destructive  action  of  the  serum 
and  would  be  readily  phagocytized  by  the  leucocytes. 

Hot  applications,  beginning  just  before  the  onset  of  the  chill, 
would  serve  to  dilate  the  peripheral  vessels  and  so  counteract 
the  vasoconstriction  for  the  time-being.  But  such  intense  and 
prolonged  heat  has  no  tendency  to  combat  the  cause,  i.  e.,  it  does 
not  produce  mobilization  of  the  leucocytes  nor  cause  them  to 
destroy  the  parasites.  On  the  contrary  it  has  the  opposite 


MALARIA  203 

effect,  viz.,  the  causation  of  an  increase  in  the  visceral  stasis  of 
leucocytes  and  red  cells  and  a  lessening  of  phagocytic  activity. 

Where  a  patient  reacts  poorly,  a  reaction  must  be  ' '  com- 
pelled "  by  the  use  of  local  hot  applications  simultaneously  with 
the  cold.  This  is  for  the  purpose  of  producing  a  sensation  of 
warmth,  while  the  essential  effect — a  brisk  activity  of  the  blood- 
vessels— is  secured  by  the  cold  application  accompanied  by  fric- 
tion or  percussion. 

The  following  suggestive  program  will  be  found  useful.  It 
must  be  varied  according  to  the  reactive  ability  of  the  patient. 
Begin  the  first  treatment  of  the  series  about  six  hours  before 
the  expected  paroxysm  and  follow  it  with  other  treatments  about 
every  two  hours.  These  should  be  continued  until  the  time  for 
the  chill  is  well  past. 

The  first  treatment  may  consist  of  an  enema  followed  by  a 
hot  foot  bath  and  two  fomentations  to  the  abdomen  of  brief  dura- 
tion. As  soon  as  the  second  fomentation  has  been  placed,  begin 
with  a  cold  mitten  friction.  This  latter  should  be  given  with 
very  cold  water  and  vigorous  friction.  Dry  the  patient  and 
let  him  rest  for  an  hour  or  an  hour  and  a  quarter.  Next  admin- 
ister quickly  alternate  hot  and  cold  to  the  spine,  followed  by  an 
alternate  hot  and  cold  percussion  douche  to  the  spine,  splenic 
and  hepatic. areas,  and  the  legs.  If  necessary  the  patient  may 
stand  in  a  tub  of  hot  water  during  this  treatment  or,  if  there  is 
still  less  reactive  ability  manifest,  give  a  hot  shower  while  the 
cold  douche  is  being  administered.  Let  the  patient  drink  freely 
of  water  both  before  and  after  each  treatment.  The  third 
treatment  may  consist  of  a  cold  shallow  rubbing  bath  lasting 
four  or  five  minutes  and  preceeded,  if  necessary,  by  a  hot  pail 
pour  to  the  legs  and  lower  spine  only.  Two  attendants  should 
be  provided  to  administer  the  shallow  bath.  Succeeding  treat- 
ments should  be  carried  on  along  the  same  line.  These  may 
be  the  cold  mitten  friction  with  ice  water,  the  wet  sheet  rub, 
the  percussion  douche,  the  salt  glow  with  pail  pour,  etc. 

In  conclusion  we  can  not  do  better  than  quote  the  principles 
given  by  Buxbaum: — u 

'  The  best  water  treatment  for  malaria  consists  in  the  employ  - 

11    Cohen's  System  of  Physiologic  Therapeutics,  Vol.  IX,  p.  136. 


804  TREATMENT  OF  FEVERS 

merit  6f  a  cold  application,  combined  with  powerful  thermic 
stimulation.  The  form  of  the  application  is  a  matter  of  indif- 
ference. The  most  important  requirement,  however,  is  the 
production  of  a  good  reaction.  When  this  fails  to  take  place, 
success  will  be  wanting.  With  the  powerful  stimulating  pro- 
cedure, which  may  be  chosen  according  to  personal  preference, 
a  fan  douche  to  the  region  of  the  spleen  may  serviceably  be 
conjoined.  The  principal  objects  of  the  therapeutist's  attention 
are  the  proper  selection  of  the  time,  and  the  production  of  a 
good  reaction .  '  The  shorter  the  interval  between  the  procedure 
and  the  anticipated  chill,  the  more  certain  the  result.  With 
regard  to  the  procedures  to  be  employed,  they  consist  in  cold 
vigorous  shower  baths,  a  cold  rub  in  course  sheets  in  combina- 
tion with  sheet  baths;  cold  sitz  baths  of  ten  minutes'  duration; 
cold  full  baths;  plunge  baths  and  other  suitable  measures.  The 
treatment  should  be  continued  until  the  constitution  of  the 
blood,  the  digestion,  and  circulation  are  restored  to  normal — 
briefly,  until  every  sign  of  cachexia  has  disappeared. 

"According  to  Strasser,  the  effect  of  hydriatic  procedures  is 
to  be  attributed  to  the  fact  that  shortly  before  the  attack  the 
infected  erythrocytes  disintegrate  under  the  influence  of  the 
powerful  stimulation  of  cold,  so  that  the  plasmodia  thus  set  free 
are  destroyed  by  the  phagocytes."  l2 

MEASLES 

Measles  is  an  acute,  contagious,  febrile  disease  characterized 
by  a  blotchy  exanthem  and  accompanied  by  coryza.  It  is 
usually  uneventful  in  its  course  and  not  accompanied  by  any 
great  mortality.  However,  the  patient  may  be  made  much 
more  comfortable  during  the  febrile  period,  and  the  vital  resist- 
ance so  sustained  that  there  is  less  tendency  to  bronchopneu- 
monia.  The  eruption  does  not  appear  until  the  fourth  day,  so 
the  treatment  must  be  begun  before  a  positive  diagnosis  can  be 
made. 


Ls  J       lnt.eresting  to  note  that  Bass  and  Johns  voice  a  similar  theory  for  the  action  of 
me.  as  shown  by  the  following  quotation:     "It  is  suggested  that  quinine  has  no  de- 
Mr^i  1?' n        *      "P™   malarial   plasmodia.   its  effect  being  possibly  to  render  the  red 
Acting  the  parasite  more  permeable  to  the  all  sufficient  destructive  in  flu- 
rum.     If  this  is  true,  quinine  would  affect  only  the  parasites  in  the  circula- 
segment"  ^  lodged  in  caPillaries,  which  would  not  be  reached  by  it  until  thev 


MEASLES  205 

In  this  disease,  as  well  as  in  scarlet  fever,  the  first  thing  to 
be  accomplished  is  the  relieving-  of  the  internal  congestion 
occasioned  by  the  infective  process.  If  the  case  is  untreated, 
the  visceral  congestion  is  considerably  lessened  on  the  appear- 
ance of  the  eruption.  The  old  idea  that  measles  is  much  more 
serious  if  the  eruption  "  strikes  in,"  or  does  not  appear  frankly, 
is  not  wholly  without  foundation.  At  the  time  the  eruption 
makes  its  appearance  the  skin  becomes  markedly  congested  and 
this  serves  to,  at  least  partially,  relieve  the  visceral  congestion. 
A  treatment  which. most  efficiently  relieves  the  internal  con- 
gestion is  also  conducive  to  the  speedy  appearance  of  the  rash. 
In  our  practice  we  have  seen  this  best  accomplished  by  means 
of  some  hot  sweating  treatment,  either  the  hot  pack  or  bath, 
accompanied  by  the  drinking  of  some  hot  liquid.  The  head 
should  be  kept  cold  by  compresses  or  ice  bags.  In  some  cases, 
where  there  is  not  much  chilliness,  sweating  is  very  well 
accomplished  by  the  use  of  the  wet  sheet  pack,  prolonged  to 
the  sweating  stage.  This  draws  the  blood  from  the  viscera  and 
congests  the  skin.  At  the  termination  of  such  a  treatment,  the 
case,  if  one  of  measles,  will  show  the  characteristic  dull  red, 
blotchy  eruption. 

Baruch  recommends  some  form  of  cold  treatment  for  the  same 
purpose  and  as  an  antipyretic  throughout  the  febrile  period. 
He  prefers  the  graduated  bath,  or  a  warm  bath  in  which  the 
patient  sits  while  cold  water  is  poured  over  the  chest  and 
shoulders.  The  full  expansion  of  the  lungs  occasioned  by  such 
treatment  aids  in  the  prevention  of  bronchopneumonia.  Be- 
cause of  the  irritability  of  the  skin,  it  is  not  best  to  employ 
friction  during  the  cold  bath.  Cold  affusions  to  the  head  and 
back  of  the  neck  are  useful  in  relieving  stitpor,  delirium,  and 
other  cerebral  symptoms.  We  have  found  the  wet  sheet  pack, 
frequently  renewed  by  sprinkling  cold  water  over  it,  an  excel- 
lent means  of  reducing  the  temperature  and,  at  the  same  time, 
it  provides  against  chilliness,  since  between  each  renewal  of 
the  pack,  it  warms  up  and  reaction  is  completed.  This  maybe 
repeated  until  the  temperature  has  been  reduced  to  101°  F.,  or 
even  less.  The  evaporating  stage  of  the  pack  sh6uld  last  for  a 
greater  length  of  time  than  the  heating  stage,  so  that  the  total 
effect  will  be  that  of  heat  abstraction. 


206  TREATMENT  OF  FEVERS 

Bronchopneumonia.  Capillary  bronchitis  is  the  most  serious 
and  fatal  of  the  complications  arising-  during-  the  course  of 
measles.  In  this  disease  there  is  a  special  tendency  to  conges- 
tion of  the  mucous  membranes  of  the  respiratory  tract,  as  evi- 
denced by  the  coryza  which  invariably  accompanies  it.  The 
condition  of  the  lung's  may  prove  to  be  of  a  tubercular  nature; 
this  is  not  an  infrequent  sequel  and  one  accompanied  by  a  high 
mortality.  In  the  treatment  of  bronchopneumonia,  complicat- 
ing measles,  we  employ  the  same  methods  used  in  the  treat- 
ment of  this  disease  when  occurring:  alone.  The  child  should 
be  placed,  at  intervals  of  about  three  hours,  in  a  bath  at  90° — 
95°.  When  sufficiently  warm,  let  the  child  sit  upright  and  cold 
affusions  be  applied  to  the  chest,  shoulders,  and  back.  The 
water  for  the  affusion  may  be  at  a  temperature  of  from  70° — 
75°.  This  vigorous  means  provokes  an  unusually  deep  inspir- 
ation, which  is  followed  for  a  considerable  time,  by  slower  res- 
pirations of  greater  depth.  It  facilitates  the  expulsion  of  mucus. 

Another  treatment  that  has  given  excellent  success  is  the 
cold  compress  applied  to  the  chest.  This  should  be  wrung 
from  very  cold  water,  applied  quickly  over  the  entire  upper 
chest,  allowed  to  remain  for  a  very  short  time,  and  then  re- 
newed. This  may  be  repeated  from  two  to  four  times,  the  last 
compress  used  being  allowed  to  remain  for  thirty  to  sixty 
minutes.  The  chest  may  be  slapped  in  rapid  succession  with 
cold  wet  towels.  This,  of  course,  should  not  be  done  if  the 
temperature  is  very  high.  In  the  latter  case  the  evaporating 
wet  sheet  pack  provides  for  the  reduction  of  the  fever  and 
serves  to  stimulate  respiration.  Gaseous  interchange  and  oxy- 
genation  of  the  blood  are  greatly  promoted,  the  circulation  is 
increased,  and  the  heart  strengthened. 

Among  other  measures  that  may  be  used  to  good  advantage 
are  cold  sponging,  hot  sponging,  and  the  cold  towel  rub. 

SCARLET  FEVER 

Scarlatina  ns  an  acute,  contagious  fever  characterized  by  a 
diffuse  scarlet  erythema  and  accompanied  by  sore  throat  or 
tonsillitis.  It  has  a  higher  mortality  than  measles  and  is  accom- 


SCARLET  FEVER  207 

panied  by  more  serious  complications.  In  scarlet  fever,  as  in 
all  other  febrile  diseases,  the  chief  objects  to  be  attained  by 
treatment  are  the  maintaining  of  the  vital  resistance,  increas- 
ing phagocytosis  in  order  to  combat  the  infection,  sustaining 
the  heart  and  circulation,  and  controlling  the  nervous  manifes- 
tations by  tonic  measures.  Before  the  appearance  of  the  erup- 
tion, scarlet  fever  should  be  treated  in  precisely  the  same  man- 
ner as  measles.  Usually  by  the  time  the  physician  is  called, 
the  eruption  has  already  begun  to  make  its  appearance  and  here, 
as  in  measles,  we  have  foun'd  the  use  of  the  initial  hot  bath  or 
pack  most  effectual  in  promoting  a  decided  and  general  erup- 
tion. As  soon  as  its  appearance,  or  other  symptoms  give  evi- 
dence that  the  internal  congestion  has  been  materially  relieved, 
some  form  of  cold  treatment  should  immediately  follow.  Be- 
cause of  the  soar  throat  and  tonsillitis,  it  may  be  necessary  to 
precede  the  general  hot  treatment  by  fomentations  to  the  neck 
and  upper  chest.  Cold  compresses  or  ice  bags  should  be 
applied  to  the  head  at  the  same  time,  and  the  treatment  accom- 
panied by  a  hot  foot  bath  or  leg  pack.  These  partial  hot  appli- 
cations in  themselves  may  produce  general  perspiration,  in 
which  case,  it  is  imnecessary  to  use  other  hot  treatment.  A  full 
hot  bath  may  be  serviceable  in  place  of  the  hot  pack,  and  when 
the  patient  has  become  thoroughly  warmed,  the  succeeding 
cold  treatment  may  be  applied  by  proper  graduation  of  the  bath. 
The  temperature  must  not  be  reduced  too  far,  since  it  is  im- 
possible to  employ  friction  on  account  of  the  rash. 

The  wet  sheet  pack,  kept  at  the  evaporating  stage  and  fre- 
quently renewed,  is  a  very  efficient  means  of  reducing  the  tem- 
perature, energizing  the  nerves  and  circulation.  After  the 
eruption  has  once  appeared  there  need  be  no  fear  of  ' '  driving 
the  rash  in."  However,  it  is  necessary  to  produce  a  decided 
cutaneous  reaction  with  every  cold  treatment  used.  The  ex- 
treme cold  bath  is  contraindicated.  Affusions  and  ablutions, 
beginning  with  water  at  90°  gradually  lowering  the  tempera- 
ture until  water  at  70°  or  75°  is  used,  are  also  useful  in  con- 
trolling the  temperature  and  assisting  the  heart's  action. 

It  is  necessary  that  the  patient  drink  a  considerable  quantity 
of  water  to  provide  for  thorough  elimination,  because  of  the 


208  TREATMENT  OF  FEVERS 

tendency  to  renal  congestion  and  nephritis.  This  latter  con- 
dition is  the  most  important  complication  of  scarlet  fever. 

Nephritis.  Should  this  condition  appear  during  the  febrile 
period,  it  is  not  necessary  to  stop  all  cold  treatments,  but  the 
temperature  should  be  somewhat  moderated  and  the  time 
shortened.  Short  hot  applications  may  be  made  so  as  to  en- 
hance the  reactive  ability,  and  these  immediately  followed  by 
such  measures  as  cold  affusions,  cold  sponging,  wet  sheet  pack, 
or  the  graduated  bath.  In  the  case  of  the  graduated  bath,  the 
initial  heating  may  be  accomplished  by  beginning  the  bath  at 
95°— 98°,  raising  the  temperature  a  few  degrees  until  the 
patient  is  well  warmed,  and  then  gradually  cooling  the  bath  to 
80°  or  85°.  Chilliness  should  not  result  from  any  treatment, 
as  this  tends  to  increase  the  renal  congestion. 

If  the  wet  sheet  pack  is  used,  the  sheet  may  be  wrung  from 
hot  water  and  then  maintained  at  the  evaporating  stage  and 
renewed  by  sprinkling  cold  water  over  the  sheet.  During  all 
this  time,  the  drinking  of  large  quantities  of  water  should  be 
encouraged.  If  the  nephritis  should  make  its  first  appearance 
after,  or  at  the  close  of,  the  febrile  period,  it  is  perhaps  best  to 
employ  the  means  commonly  used  in  treating  nephritis,  that  is, 
diaphoretic  measures.  The  hot  bath  with  ice  to  the  head  and 
heart,  the  hot  blanket  pack,  or  partial  hot  applications,  such  as 
the  hot  foot  bath  accompanied  by  fomentations  to  the  spine, 
chest,  or  abdomen,  are  all  useful  in  producing  sweating.  The 
hot  air  bath  may  be  administered  in  bed  according  to  the  plan 
mentioned  under  acute  nephritis.  If  the  hot  blanket  pack  is 
used,  it  may  be  very  conveniently  followed  by  the  wet  sheet 
pack,  wrung  from  water  at  75°  and  continued  to  the  sweating 
stage.  Reaction  should  ensue  promptly.  The  child  may  be 
left  in  this  pack  an  hour  or  two,  or  until  the  sheet  is  nearly  dry. 

The  cold  towel  rub  and  cold  mitten  friction  may  be  used  to 
promote  circulatory  reaction,  providing  desquamation  has  well 
begun.  It  is  best  not  to  employ  the  cold  mitten  friction,  should 
the  nephritis  occur  before  the  eruption  subsides.  Under  these 
treatments,  the  albumen  gradually  lessens  and  casts  disappear 
from  the  urine.  Should  there  be  edema  about  the  feet  and 
ankles,  the  alternate  hot  and  cold  foot  or  leg  bath  should  be 


INFLUENZA  209 

used  and  followed  by  centripetal  massage.  To  aid  desquama- 
tion  and  prevent  spreading-  of  the  contagion,  the  cold  mitten 
friction  or  salt  glow  may  be  used  to  hasten  the  removal  of  the 
scales.  Either  treatment  should  be  followed  by  an  oil  rub  to 
prevent  further  rubbing  off  of  the  contagion-carrying  epi- 
thelium. 

Endocarditis.  Should  this  complication  arise,  all  cold  tub 
baths  should  be  discontinued,  also  cold  affusions.  The  patient 
must  be  kept  at  absolute  rest,  with  the  ice  bag  to  the  heart 
intermittently.  After  the  eruption  has  disappeared,  there  is  no 
measure  equal  to  the  cold  mitten  friction  in  assisting  the  circu- 
lation and  relieving  the  heart.  For  further  treatment,  see 
endocarditis  in  rheumatic  fever. 

LA  GRIPPE— INFLUENZA 

The  clinical  condition  in  influenza  is  quite  different  from  that 
of  typhoid  fever.  In  this  disease,  the  fever  is  of  the  short, 
high  type,  with  rapid  pulse  and  high  blood  pressure.  These 
are  the  manifestations  that  are  found  in  young  adults.  With 
older  persons,  the  disease  is  quite  likely  to  be  accompanied  by 
considerable  asthenia,  the  digestive  system  and  the  nervous 
system  bearing  the  brunt  of  the  infective  process.  With 
younger  persons  the  respiratory  tract  is  more  likely  to  be 
affected . 

Since  this  is  a  short  sthenic  fever,  the  treatment  employed 
will  differ  considerably  from  that  used  in  typhoid  fever.  Aside 
from  cold  applications  to  the  head,  it  is  unnecessary  to  employ 
long  cold  treatments  for  the  purpose  of  reducing  the  fever  and 
all  generalized  cold  applications  are  contraindicated.  With  an 
individual  that  has  been  previously  strong  and  well  and  is  in 
good  flesh,  it  may  be  possible  to  treat  the  case  from  the  start 
by  vigorous  cold  applications  with  friction.  This  enhances  the 
vital  resistance,  increases  leucocytosis  and  so  combats  the  in- 
fection in  a  very  direct  manner. 

With  cases  as  they  usually  present  themselves,  we  have  ob- 
tained the  best  results  by  the  use  of  an  initial  sweating  treat- 
ment such,  for  example,  as  the  hot  leg  bath  accompanied  by 
fomentations  to  the  spine  or  to  the  chest  and  throat,  with  cold 

14 


HO  TREATMENT  OF  FEVERS 

compresses  to  the  head  and  neck.  (Plate  IX.}  At  the  same 
time,  the  patient  should  drink  several  glasses  of  hot  lemonade. 
Chilliness  is  soon  overcome  and  the  patient  begins  to  perspire 
profusely.  As  soon  as  profuse  perspiration  is  well  established, 
the  patient  may  be  given  a  graduated  shower  beginning  at 
about  110°,  gradually  increasing  the  temperature  to  the  limit  of 
toleration.  While  in  the  hot  spray,  the  patient  should  wear  a 
cold  compress  to  the  head.  As  soon  as  he  is  again  well  warmed, 
the  temperature  should  very  gradually  be  reduced  to  90°.  This 
abstracts  much  of  the  heat  that  has  been  communicated  to  the 
body  by  the  sweating  treatment.  The  patient  should  now  be 
put  to  bed  with  hot- water  bottles  to  the  feet,  and  allowed  to 
perspire  gently  for  a  number  of  hours. 

Great  care  must  be  taken  that  the  patient  is  not  overheated 
by  the  sweating  treatment,  since  fainting  is  quite  likely  to 
result  unless  the  cold  compresses  to  the  head  and  neck  are  fre- 
quently renewed.  In  some  cases  it  is  necessary  that  the  patient 
be  in  a  recumbent  position  while  taking  the  treatment  and,  for 
this  reason,  the  horizontal  electric  light  cabinet  is  very  service- 
able in  securing  free  diaphoresis.  The  use  of  the  upright 
cabinet  at  the  onset  of  la  grippe  is  almost  certain  to  result  in 
fainting. 

In  case  this  sweating  treatment  has  been  carried  out  in  the 
evening,  on  the  following  morning  the  patient  should  be  treated 
by  preliminary  hot  applications  for  the  purpose  of  relieving,  the 
aching  of  the  back  and  limbs.  This  is  best  accomplished  by 
the  leg  pack  and  large  fomentations  to  the  spine.  They  should 
not  be  continued  long  and  should  be  followed  immediately  by 
a  vigorous  cold  mitten  friction.  From  this  point  on,  it  is  best 
to  treat  the  case  as  far  as  possible  with  tonic  measures,  such  as 
the  cold  mitten  friction,  cold  towel  rub,  or  the  hot  and  cold 
douche  to  the  spine  and  legs,  finishing  with  the  alternating 
douche  to  the  feet.  The  sweating  treatment  should  not  be 
repeated  unless  it  seems  quite  necessary. 

Any  plan  of  treatment  may  fail  of  its  best  results  in  case  the 
bowel  is  not  thoroughly  unloaded  at  the  beginning.  This  may 
be  best  accomplished  by  thorough  enemata.  Special  complica- 
tions require  attention  outside  of  the  general  plan  of  treating 


PLATE  IX.     A  sudorific  treatment  to  be  given  at  the  onset  of  influenza. 


INFLUENZA  211 

influenza.  Bronchitis  and  cough,  with  pain  in  the  chest, 
should  be  treated  by  large  fomentations,  followed  by  the  heat- 
ing- chest  pack.  Pharyngitis  or  tonsillitis  should  be  treated  in 
the  same  manner,  that  is,  with  fomentations,  and  a  cold  heating 
compress  applied  between  treatments.  The  nervous  symptoms 
are  best  met  by  the  ice  cap,  or  cold  compress  to  the  head.  The 
pain  may  be  very  materially  relieved  by  the  use  of  very  hot 
fomentations.  In  all  cases,  however,  the  treatment  should  be 
concluded  with  a  vigorous  cold  mitten  friction.  It  is  not 
designed  that  the  cold  frictions  shall  materially  lower  the  tem- 
perature in  and  of  themselves,  that  is,  the  fall  in  temperature 
does  not  result  immediately  after  the  application,  but  rather 
succeeds  in  a  few  hours.  If  the  temperature  is  very  high,  it 
may  be  effectually  combated  by  the  use  of  the  ice  bag  to  the 
heart  with  ice  applications  to  the  head.  Both  should  be  con- 
tinued with  but  little  interruption. 

The  asthenic  type  of  influenza,  except  in  old  people  or  chronic 
invalids,  is  not  now  as  common  as  during  the  pandemic  of  1889 
and  the  years  immediately  following.  In  the  event  of  severe 
asthenia  the  treatment  is  to  be  carried  on  along  general  lines 
with  special  reference  to  those  measures  which  will  sustain  the 
heart  and  circulation.  The  treatment  of  respiratory  or  diges- 
tive complications  demands  special  care  and  is  to  be  carried  on 
along  lines- laid  down  elsewhere. 


CHAPTER    XVIII 

INFLAMMATION  AND  ANTIPHLOGISTIC 
EFFECTS 

BEFORE  considering:  the  conditions  present  in  inflammations 
and  their  treatment,  it  will  be  well  to  understand  the  prin- 
ciples involved  in  the  production  of  certain  circulatory  effects 
which  are  much  used  in  the  treatment  of  inflammations.  We 
shall,  therefore,  first  turn  our  attention  to  the  methods  and 
principles  concerned  in  the  production  of  depletion  and  fluxion. 

Depletion  is  the  reduction  of  congestion  in  a  gfiven  part  or 
organ. 

Derivation  is  depletion  secured  by  the  withdrawing  of  blood 
from  an  organ  or  part  of  the  body  by  increasing  the  amount  of 
blood  in  some  other  part.  Practically,  it  is  the  reduction  of 
congestion  (and  inflammation)  by  drawing  the  blood  from  the 
part  congested  into  some  other  part.  There  is  produced  a  col- 
lateral hyperemia  with  local  anemia. 

Fluxion  consists  in  increasing  the  rapidity  of  the  blood  cur- 
rent in  a  particular  part,  and  consequently,  the  total  amount 
of  blood  passing  through  that  part  in  a  given  time.  It  is  the 
production  of  arterial  hyperemia. 

DEPLETION— DERIVATION 

There  are  three  practical  methods  of  securing  depletion: 
first,  by  the  application  of  heat  alone;  second,  by  the  applica- 
tion of  cold  alone;  and  third,  by  the  application  of  both  heat  and 
cold  applied  simultaneously.  The  accompanying  outline  shows 
in  a  condensed  form  the  principal  points  of  each  method. 

(212) 


te  K  ? 
fc  3.2 

III 


DEPLETION 


213 


Application 

Heat 
alone 


Cold 
alone 


Methods  of  Securing  Depletion 

Where  Placed  Mode  of  Action  Examples  of  Use 

Derivation 


Col  late  ral — o  ve  r 
part  or  at  a  dis- 
tance 

Proximal  or  di- 
rectly over  part 


Heat  and     Cold   over    part 
cold  sim-     or  proximal 
ultane-     Heat  collateral 
ously 


Direct  or 
reflex 


Reflex 
Derivation 


Pleurisy 
Renal  con- 
gestion 

Acute  rheu- 
matism, in- 
fectious ar- 
thritis 

Acute  appen- 
dicitis 

Acute  salpin- 
g-itis 


Simultaneous  Heat  and  Cold.  Depletion  is  most  effectually 
secured  by  the  simultaneous  application  of  both  heat  and  cold 
in  the  following'  manner  {Plate  X.):  A  large  very  hot  applica- 
tion is  made  to  a  distant  part;  in  many  cases,  it  extends  up  to 
and  includes  the  congested  part.  At  the  same  time  ah  ice  bag", 
ice  pack,  or  ice  compress  is  placed  directly  over  the  inflamed 
organ.  In  this  way  collateral  hyperemia  is  secured  and  the 
local  anemia  reenforced  by  the  direct  or  reflex  vasoconstrict- 
ing  influence  of  the  ice.  The  local  anemia  is  made  extreme 
by  both  a  "  push  "  and  a  "  pull  "  effect  on  the  circulation,  the 
"  pull  "  being  secured  by  the  vis  a  fronte  of  the  hot  application, 
and  the  ' '  push  ' '  by  the  vis  a  tergo  of  the  reflex  contraction  of 
the  blood-vessels,  due  to  the  cold  application  over  the  part. 
The  most  effective  derivation  is  secured  by  direct  contact  of  the 
body  with  hot  water.  A  hot  leg"  bath  is  more  effective  than  a 
hot  leg  pack,  and  a  hot  leg  pack  with*  the  wet  blanket  applied 
directly  to  the  skin  is  more  effective  than  where  a  dry  blanket 
intervenes.  Neither  the  local  hot  air  bath  or  the  local  electric 
light  bath  (or  either  as  a  general  application)  are  as  effective 
as  a  hot  pack  or  a  local  hot  bath.  The  reason  for  this  difference 
is  found  in  the  fact  that  the  blood-vessels  dilate  to  a  much 
greater  extent  under  the  action  of  hot  water  applied  directly 
to  the  skin  surface.  The  hot  air  bath  and  the  electric  light 
bath  may  produce  more  profuse  perspiration,  but  the  blood- 


g!4  ANTIPHLOGISTIC  EFFECTS 

vessels  do  not  dilate  to  the  same  degree  possible  under  the 
action  of  hot  water.  However,  in  the  case  of  a  very  hot  full 
tub  bath  and  a  hot  blanket  pack,  the  surface  derivation  is  so 
extreme  in  the  former  case  as  to  cause  fainting:  when  it  is  first 
entered,  with  congestion  of  the  brain  later  on  because  of  the 
general  rise  in  blood  pressure.  For  this  reason,  the  full  tub 
bath  for  extreme  derivation  is  not  a  practical  application,  and 
in  practice  we  use  the  hot  blanket  pack  with  the  continuous 
application  of  ice  to  the  head  and  neck  and  also  to  the  heart 
if  necessary. 

The  following  are  the  principal  derivative  measures  indicated 
in  the  acute  stage  of  the  diseases  mentioned: — 

1.  APPENDICITIS.     Hot  hip  and  leg  pack,  with  ice  bag  over 
the  appendix. 

2.  PERITONITIS.     Hot  hip  and  leg  pack,   or  leg  pack  only, 
with  ice  compress  or  ice  bags  to  the  abdomen. 

3.  PUERPERAL  INFECTION  AND  ACUTE  SALPINGITIS.       Full 
hot  blanket  pack,  or  hip  and  leg  pack,  with  ice  to  the  pelvis. 

4.  ACUTE  CONGESTION  OF  THE  LUNGS.     Hot   leg  bath,   hip 
and  leg  pack,  or  full  blanket  pack,  with  or  without  cracked  ice 
compress  over  the  lobe  affected. 

5.  MENINGITIS.     Hot  leg  pack,  with  ice  cravat,  ice  cap  and  ice 
bag  to  the  base  of  the  brain  and  the  upper  spine. 

6.  MASTOIDITIS.     Hot  leg  bath  with  ice  cravat  or  ice  bag 
over  carotid  artery,  ice  cap,  and  fomentations  to  the  mastoid. 

7.  ALVEOLAR  ABSCESS.     Same  as  above,  except  fomentations 
to  the  jaw. 

8.  ACUTE  OSTEOMYELITIS  (of  tibia) .     Fomentations  to  leg,  or 
leg  pack,  with  ice  over  the  femoral  artery. 

9.  CEREBRAL  CONGESTION.     Hot   leg  bath  with  ice  cravat, 
ice  cap,  or  cold  compress  to  the  entire  face  and  cranium. 

10.  RENAL  CONGESTION.  Fomentations  to  back;  hot  trunk 
pack  or  full  blanket  pack,  with  ice  bag  over  lower  third  of 
sternum. 

Precautions:  In  order  to  maintain  collateral  hyperemia,  the 
treatment  must  be  concluded  with  such  a  vigorous  tonic  meas- 
ure as  a  cold  mitten  friction  applied  to  the  part  previously 
covered  by  the  hot  application.  The  hot  application  alone  pro- 


DEPLETION  215 

duces  passive  dilatation  of  the  blood-vessels.  If  the  treatment 
is  stopped  here,  the  circulation  will  soon  equalize  itself,  or  even 
a  worse  internal  congestion  may  occur.  The  cold  mitten  fric- 
tion, however,  produces  an  active  dilatation  (alternate  dilata- 
tion and  contraction)  of  the  blood-vessels,  thus  maintaining-  for 
a  longer  time  the  derivation  secured  by  the  hot. 

Depletion  by  Heat  Alone.  In  some  cases  sufficient  blood  can 
be  withdrawn  from  a  part  by  applying  heat  over  the  cutaneous 
branches  coming  from  the  artery  supplying  the  deeper  con- 
gested part  or  organ.  In  this  case  the  larger  flow  of  blood  is 
diverted  into  the  cutaneous  (and  superficial)  branches,  leaving 
less  to  pass  to  the  deeper  branches.  Examples  of  this  are 
found  in  the  treatment  of, — 

1.  PLEURISY.  Large  fomentations  to  the  chest  divert  the 
blood  flowing  in  the  intercostal  and  internal  mammary  arteries 
from  the  pleural  branches  to  the  posterior,  lateral,  and  anterior 
cutaneous  branches. 

2  RENAL  CONGESTION.  Large  fomentations  over  the  lower 
dorsal  and  lumbar  spine  the  entire  width  of  the  back.  This 
diverts  the  blood  from  the  renal  arteries  to  the  lower  intercostal 
and  lateral  lumbar  branches  of  the  aorta. 

3.  SIMPLE  SPINAL  CONGESTION.     Large  fomentations  to  the 
spine  divert  the  blood  from  the  spinal  arteries  to  the  posterior 
cutaneous  arteries  supplying  the  skin  and  muscles  of  the  back. 

4.  CONGESTIVE  SCIATICA.     Large  fomentations  to  back  and 
side  of  thigh  divert  the  blood  from  the  nerve  to  the  skin. 

5.  TRIGEMINAL  NEURALGIA.     Fomentations  to  side  of  face 
divert  the  blood  to  the  skin.     This  may  be  reenforced  by  the 
use  of  an  ice  bag  over  the  carotid,  thus  mechanically  lessening 
the  total  volume  of  blood  going  to  the  head. 

Precautions:  In  pleurisy  and  neuralgia,  cold  increases  the 
pain,  hence  can  not  be  used  over  the  seat  of  the  pain. 

Depletion  by  Cold  Alone.  In  a  few  conditions  a  congestion 
or  inflammation  may  be  sufficiently  reduced  by  the  use  of  ice 
or  other  cold  application  applied  directly  over  the  part  or  over 
the  artery  supplying  the  part,  without  the  addition  of  collateral 
heat.  In  acute  articular  rheumatism  and  other  acute  infectious 
arthritides  this  method  is  most  effective,  in  fact  in  our  experi- 


216  ANTIPHLOGISTIC  EFFECTS 

ence,  almost  specific.  In  some  cases  of  brain  congestion  ice 
over  the  carotids  and  cold  applications  to  the  head  and  face  are 
all  that  is  needed.  In  the  early  stage  a  boil  may  be  aborted 
by  applying"  an  ice  bag  directly  over  the  seat  of  the  infection. 

FLUXION 

When  hot  and  cold  applications  are  used  to  secure  depletion, 
they  are  used  simultaneously  and  to  different  areas.  If  the  hot 
and  cold  are  used  alternately  and  to  the  same  area,  the  result  is 
fluxion.  This  may  be  either  by  direct  effect  in  the  part 
treated,  or  by  reflex  action  in  a  related  part.  This  effect  is 
intensified  by  friction  or  percussion. 

All  alternate  hot  and  cold  applications  are  tonic,  both  locally 
and  generally.  We  may  here,  for  the  sake  of  clearness  and 
brevity,  confine  ourselves  to  the  consideration  of  measures 
desired  to  produce  chiefly  violent  circulatory  reaction  in  a  given 
part  or  organ. 

The  following  are  the  principal  means  used  to  produce 
fluxion: — 

1.  Alternate  hot  and  cold,   using  fomentations  and   ice,   or 
fomentations  and  cold  compresses  (revulsive  compress). 

2.  Alternate  hot  and  cold  douches  or  sprays,   as   to  spine, 
legs,  liver,  etc. 

3.  Alternate  hot  and  cold  packs. 

4.  Alternate  hot  and  cold,  as  to  head  or  kidneys  and  sternum. 

5.  Revulsive  or  alternate  hot  and  cold  sitz  bath. 

6.  Alternate  hot  and  cold  foot  or  leg  bath. 

7.  Alternate  hot  and  cold  immersion,  as  of  hand  and  arm. 

8.  Alternate  hot  and  cold  vaginal  douche,  rectal  irrigation,  etc. 
In  all  the  above  measures,  the  condition  prodiiced  is  that  of 

active  (arterial)  hyperemia.  The  alternate  dilatation  and  con- 
traction of  the  blood-vessels  is  stimulated.  This  condition  is 
known  as  active  dilatation.  These  alternating  changes  of  vaso- 
constriction  and  vasodilatation  are  more  rapid  and  extreme  than 
the  normal.  They  very  markedly  increase  the  number  of  white 
blood  cells  in  a  given  part,  and  consequently  the  resulting 
phagocytosis.  It  is  this  which  makes  it  especially  valuable, 
and  almost  indispensable  in  some  acute  congestions  and  inflam- 


FLUXION  217 

mations,  such  as  an  acute  infection  of  a  hand  or  a  foot,  where 
lymphangitis  and  lymphadenitis  are  likely  to  follow  so  quickly. 

Perhaps  the  largest  field  for  the  use  of  fluxion  (arterial  hyper- 
emia)  is  in  chronic  congestions,  whether  a  sequel  to  chronic 
infections  or  non-inflammatory.  In  these  cases  the  congestion 
is  of  a  passive  type,  i.  e.,  venous  stasis.  The  treatment  is  also 
indicated  in  local  anemias. 

Below  are  given  some  of  the  more  important  indications  for 
the  use  of  fluxion: — 

1.  Acute  infections,  as  of  hand,  arm,  or  foot. 

2.  Convalescence  from  all  local  infections  (stage  of  passive  or 
venous  congestion). 

3.  Chronic  congestion  of  liver. 

4.  Chronic  pelvic  congestion,  as  of  uterus  or  adnexa,  whether 
simple  or  following  infections. 

5.  Uterine  subinvolution. 

6.  Amenorrhea, 

7.  Myelitis  (chronic  stage). 

8.  Locomotor  ataxia  and  other  paralyses  of  spinal  origin  (in 
chronic  stage). 

9.  Alcoholic  neuritis  (after  acute  stage). 

10.  Muscular  atrophies. 

11.  Tubercular  arthritis  and  synovitis. 

12.  Chronic  osteomyelitis. 

13.  Varicose  ulcer. 

Precautions:  In  acute  infections,  massage  effects,  such  as 
friction  or  percussion,  should  be  avoided.  Dire  effects  in  the 
quick  spread  of  the  bacteria  to  other  parts,  will  result  if  these 
are  used. 

Revulsion.  According  to  Borland,  this  term  is  synonomous 
with  derivation  and  depletion.  Kellogg  evidently  uses  it  to 
designate  the  mode  of  giving  a  hot  and  cold  application,  the 
chief  effect  of  which  is  fluxion,  for  example,  a  revulsive  com- 
press— a  treatment  consisting  of  a  single  prolonged  hot  appli- 
cation, followed  by  a  single  very  brief  application  of  cold. 

Again  it  is  used  to  designate  derivation  secured  by  collateral 
fluxion,  as  in  the  use  of  the  hot  and  cold  foot  or  leg  bath,  or  a 


218  ANTIPHLOGISTIC  EFFECTS 

hot  and  cold  percussion  douche  to  the  feet  and  leg's  to  relieve 
cerebral  congestion.  When  hot  and  cold  are  alternately  applied 
to  one  part  of  the  body,  thus  producing-  fluxion  in  that  part,  it 
will  withdraw  more  or  less  blood  from  other  related  or  distant 
parts.  This  diverse  application  of  the  term  has  led  to  no  little 
confusion.  While  the  term  can  not  be  fully  dispensed  with, 
the  student  should  bear  in  mind  that  the  effect  is  that  of.  either 
derivation  or  fluxion. 

PATHOGENESIS  OF  INFLAMMATION 

Inflammation  consists  of  the  series  of  changes  constituting: 
the  local  manifestation  of  the  attempt  at  repair  of  actual  or 
referred  injury  to  a  part,  or  briefly,  it  is  the  local  attempt 


A  B 

Fig.  50.  A— arterioles  and  capillaries,  normal,  B— the  same  after 
introduction  of  an  irritant  foreign  body  and  the  beginning  of  inflam- 
mation. 

at  repair  of  actual  or  referred  injury.  Inflammation  is  the 
reaction  of  irritated  and  damaged  tissues  which  still  retain 
vitality."  ] 

The  pathologic  conditions  in  an  inflammatory  process  may  be 
partially  understood  by  the  five  cardinal  symptoms,  viz., — 

1.  Rubor — redness. 

2.  Tumor — swelling. 

3.  Calor — heat. 

4.  Dolor — pain. 

5.  Functio  laesa — loss  of  function. 

The  primary  cause  of  the  inflammation,  whatever  it  may  be, 
is  responsible  for  these  conditions,  which  are  largely  circula- 
tory disturbances.  The  condition  in  the  acute  stage  is  one  of 
(1)  arterial  hyperemia  {Fig.  50.}  with  (2)  a  serous  exudate, 

1    Adami— Inflammation,  pp.  5.  227. 


PRINCIPLES  OF  TREATMENT  219 

and  (3)  an  increasing  number  of  leucocytes  in  the  blood  stream 
and  tissues;  from  the  latter,  they  return  to  the  blood  stream 
less  rapidly  than  normal.  (4)  The  inflamed  part  is  bright  red. 
(5)  The  pain  is  severe  and  *  of  ten  throbbing-  in  character 
because  of  the  increasing  tension  on  the  nerves  caused  by  the 
swelling.1' 

In  the  chronic  stage,  the  condition  is  one  of  (l)  venous  con- 
gestion (passive  hyperemia).  (2)  There  is  a  beginning  organ- 
ization of  the  exudate,  and  (3)  a  dearth  of  leucocytes.  (4)  The 
part  is  of  a  dark  red  or  bluish  color.  (5)  The  pain  is  less 
severe,  and  described  as  dull  and  heavy  in  character.  In  the 
intermediate  stages,  the  inflammatory  process  passes  gradually 
from  the  first  to  the  last  condition.  The  circulation  begins  to 
be  slowed,  and  more  and  more  blood  accumulates  in  the  capil- 
laries and  veins,  less  arterial  blood  being  present,  so  that  the 
total  amount  of  blood  in  the  organ  is  increased  above  normal. 
The  severe  or  throbbing  pain  gives  way  to  the  more  constant, 
but  less  severe,  dull  pain.  The  leucocytes  find  their  way  back 
into  the  circulation  (lymphatic  or  blood)  if  no  suppuration 
occurs,  and  the  number  in  the  tissue  decreases. 

PRINCIPLES  OF  TREATMENT 

In  the  Acute  Stage.  (l)  Limit  the  congestion,  (2)  hasten 
the  absorption  of  the  exudate  and  prevent  further  exudation, 
(3)  energize  and  assist  the  phagocytes  in  combating  the  infec- 
tion or  noxious  agent,  (4)  relieve  the  pain.  While  inflamma- 
tion is  a  protective  process,  it  must  not  be  supposed  that  it  is 
always  well  regulated,  or  able,  unassisted,  to  cope  with  the 
disturbing  cause. 

The  serous  exudate  of  this  stage  consists  of  a  more  concen- 
trate lymph  than  normal,  z.  <?.,  a  lymph  containing  more  pro- 
teins, which  doubtless  serve  for  the  nutrition  of  the  cells  neces- 
sary in  the  regeneration  of  tissue  which  follows.3  It  is  neces- 
sary only  to  limit  this  to  a  proper  amount  and  hasten  its  return 
to  the  blood -and  lymph  vessels  when  its  work  is  done.  This 
means  the  restoration  of  the  proper  rate  of  exudation  and  absorp- 
tion and  is  applicable  to  the  leucocytes  as  well  as  the  fluids. 

2  For  the  details  of  the  process,  see  Adami — Inflammation,  pp.  34 — 36. 

3  Starling— Fluids  of  the  Body.  p.  174. 


M0  ANTIPHLOGISTIC  EFFECTS 

In  the  Chronic  Stage,  (l)  Stimulate  and  quicken  the  circu- 
lation by  the  production  of  arterial  hyperemia,  and  (2)  stimu- 
late the  process  of  phag-ocytosis,  thus  (3)  promoting:  resolution 
and  absorption  of  the  exudate  and  thereby  preventing  its 
organization . 

In  the  acute  stage  of  an  inflammation,  i.  e.,  during  the  first 
few  hours  or  first  day  or  two,  extreme,  cold  should  be  vised  over 
the  part  continuously,  or  with  only  short  intermissions,  in 
order  to  lessen  the  congestion,  relieve  the  pain,  and,  if  possible, 
thereby  abort  the  inflammation.  In  many  cases  it  is  necessary 
to  reenforce  the  continuous  cold  by  hot  applications  to  collateral 
areas  (derivation)  in  order  to  effectually  reduce  the  congestion. 
The  cold  energizes  the  white  blood  cells,  increasing  their  num- 
ber and  efficiency  in  the  destruction  of  bacteria,  and  hastens 
their  return  to  the  blood  stream. 

After  the  acute  stage  has  passed,  i.  e.,  at  the  end  of  a  few 
hours,  or  on  the  second  day,  the  cold  applications  should  be 
replaced  by  a  heating  compress;  or,  if  cold  compresses  were 
used  in  the  first  stage,  it  is  only  necessary  to  leave  them  on, 
thus  making  a  heating  compress.  These  cold  and  heating 
compresses  should  be  replaced  at  intervals  of  one  to  three 
hours,  using  short  fomentations  when  the  change  is  made. 

As  the  inflammation  progresses  toward  the  chronic  stage, 
more  heat  and  less  cold  should  be  used.  After  the  acuteness 
of  the  inflammation  has  entirely  subsided,  the  most  vigorous 
hot  and  cold  applications  should  be  used  in  order  to  lessen 
venous  stasis  and  bring  to  the  organ  a  greater  supply  of  fresh 
blood  (fluxion),  for  the  time  producing  an  arterial  hyperemia. 
It  is  possible  to  use  fluxion  even  immediately  following  the 
first  few  hours  of  some  inflammations,  provided  they  are  not  in 
a  dangerous  area,  i.  <?.,  where  rupture  would  prove  fatal  or 
produce  serious  complications. 

It  has  been  shown  that  in  some  cases  the  maintenance  of  a 
high  external  temperature  is  conducive  to  a  more  rapid  and 
benign  course  of  the  inflammation  than  where  cold  is  used. 
These  are  doubtless  cases  of  inadequate  reaction  as  suggested 
by  Adami,4  better  results  being  due  to  the  increased  amount  of 

4    Inflammation,  pp.  199.  218. 


PRINCIPLES  OF  TREATMENT  221 

blood  brought  to  the  part.  In  the  majority  of  cases  still  greater 
benefit  results  from  the  use  of  alternate  hot  and  cold  applica- 
tions, since  these  produce  an  arterial  hyperemia  which  has  no 
after-tendency  to  stasis. 

The  stage  of  the  inflammation  may  best  be  judged  by  the 
color.  A  bright  red  color  is  evidence  of  an  acute  process,  and 
a  dull  red,  dusky,  or  bluish  color,  of  a  chronic  process.  Inflam- 
mations in  certain  localities  should  be  treated  by  hot  alone, 
until  after  the  first  stage  is  passed.  This  is  true  of  pleurisy. 

"For  antiphlogistic  purposes,  it  may  be  safely  held  that  in 
the  early  stage  of  congestion,  cold  applications  are  useful  so 
long  as  the  circulation  in  the  affected  part  is  still  open,  which 
is  indicated  by  the  turgor.  But  when  the  parts  assume  a 
cyanotic  hue,  when  leucocytes  have  begun  to  adhere  in  large 
numbers  to  the  vessel  wall  and  emigration  has  become  active, 
applications  of  warmth  further  the  latter  and  hasten  suppura- 
tion when  it  is  unavoidable.  The  cold  compress  diminishes 
congestion,  retards  leucocytosis  and  emigration  of  white  cells, 
while  the  warm  applications  have  the  contrary  effect,  each 
being  most  useful  in  the  respective  stage  of  inflammation. 

'  The  antiphlogistic  effects  of  cold  compresses  are  readily 
explained  by  the  results  of  Genzmer's  experiments  upon  local 
blood  letting.  He  came  to  the  conclusion  that  the  favorable 
effect  of  bleeding  upon  the  inflamed  parts  beneath  was  ascrib- 
able,  not  to  their  becoming  more  anemic,  but  to  the  fact  that 
the  blood  Stream  became  more  rapid,  and  thus  the  corpuscles 
which  had  adhered  to  the  vessel  walls  were  loosened  and  driven 
into  the  general  circulation.  The  fluxion,  therefore,  which  the 
application  of  cold  or  warm  compresses  produces,  in  the  parts 
below  them,  is  the  true  cause  of  the  changes  in  the  latter  when 
inflamed.  Thus  may  the  old  theory  of  derivation  be  satisfac- 
torily explained. 

'  This  effect  of  cold  applications  may  be  called  into  action  in 
some  local  inflammations  in  which  the  parts  appear  cyanotic 
and  it  is  important  to  prevent  impending  suppuration.  Here 
hot  compresses  or  cataplasms  are  also  useful,  to  arouse  the 
surface  circulation;  as  they  cool  off,  they  widen  the  deeper 
vessels  and  thus  reestablish  the  circulation  wrhich  has  become 


ANTIPHLOGISTIC  EFFECTS 


stagnant.  This  being  accomplished,  cold  compresses  may  suc- 
ceed the  hot,  in  order  to  limit  leucocytosis  and,  by  fluxion, 
remove  stagnant  corpuscles.  It  is  evident  that  by  the  exercise 
of  sound  judgment,  the  proper  temperature  of  the  compress 
may  be  nicely  adjusted  to  each  case." 

It  must  not  be  supposed  that  circulatory  changes  are  the 
only  effects  produced  by  the  treatment  outlined  above.  Proper 
regulation  of  the  circulation  by  means  of  heat  and  cold  also 
stimulates  the  cells  concerned  in  the  healing  process. 

From  the  above,  we  may  draw  the  following  conclusions,  as 
in  general,  applicable  to  inflammations.  During  the  acute 
stage,  the  treatment  should  be  directed  toward  the  reducing  of 
the  congestion,  whether  by  collateral  heat  alone,  or  by  heat 
assisted  by  cold  over  the  part,  or  by  cold  alone.  The  philos- 
ophy of  the  treatment  is  summed  up  in  the  word  depletion,  as 
understood  in  its  broadest  and  practical  sense,  i.  e. ,  the  reduc- 
ing of  congestion.  In  the  chronic  stage,  all  the  pathologic 
indications  are  met  by  the  production  of  fluxion.  The  accom- 
panying outline  will  serve  to  make  clear  these  principles: — 


Conditions 

1.  Arterial  hyperemia 

2 .  Increasing  serous 

exudate 

3.  Overplus  of  leuco- 

cytes 

4.  Bright  red  color 

5.  Pain  severe  and 

throbbing 

1.  Passive  hyperemia 

2.  Organization  of  ex- 

udate 


Acute  Stage 

Indications  for 
Treatment 

Limit  congestion 
Cause  absorption  of 

exudate 
Energize  leucocytes 


Relieve  pain 

Chronic  Stage 

Stimulate  circulation 
Promote  resolution 


Treatment  Should 
Produce 

Depletion 
(Reducing  of 
congestion) 


Dearth  of  leucocytes    Stimulate  leucocytosis 
Dark  red,  dusky  or  bluish  color 
Pain  less  severe  and  dull 


Fluxion 
(Production  of 
arterial  hyper- 
emia. ) 


5    Baruch-Principles  and  Practice  of  Hydrotherapy,  pp.  154.  155. 


BIER'S  HYPEREMIA  223 

We  have  already  referred  to  Bier's  hyperemic  treatment  of 
inflammation.  The  form  of  hyperemia  upon  which  Bier  places 
the  greatest  emphasis  and  which  he  lauds  most  highly  is  the 
passive  hyperemia  produced  by  lightly  constricting  bands, 
suction  cups,  etc.  These  partially  obstruct  the  return  flow,  of 
venous  blood,  so  producing  a  stasis  in  the  part.6  The  writer 
can  see  no  rational  basis  for  this  procedure;  in  fact,  to  us,  it 
appears  decidedly  irrational  and  to  in  no  way  meet  the  needs 
of  a  chronic  inflammation.  In  chronic  inflammation  there  is 
already  an  extreme  venous  stasis.  To  still  further  slow  the 
blood  current,  certainly  does  not  tend  toward  a  normal  condi- 
tion.7 The  leucocytes  are  neither  renewed,  increased,  or  ener- 
gized. The  blood,  already  overcharged  with  acid  products,  is 
in  no  way  restored  to  its  normal  degree  of  alkalinity.  On  the 
contrary,  the  production  of  active  hyperemia  meets  all  these 
needs  as  pointed  out  above. 

Meyer  recognizes  only  three  methods  of  producing  hyper- 
emia; viz. ,  by  elastic  bandages,  cupping  glasses,  and  hot  air.8  Of 
these  only  the  hot  air  produces  an  active  hyperemia,  and  while 
it  is  exceedingly  useful  in  many  cases,  it  does  not  produce  the 
most  ideal  vascular  condition  for  the  relief  of  chronic  inflam- 
mations since  the  blood-vessels  are  passively  dilated  with  con- 
sequent stasis  afterward.  The  active  hyperemia  continues  only 
during  the  treatment  and  for  a  very  short  time  after  the  appli- 
cation of  the  hot  air. 

While  the  ice  bag  over  an  inflamed  part,  accompanied  by 
collateral  heat  for  derivative  purposes,  effectually  relieves  the 
pain  of  an  inflammatory  process  in  soft  tissue,  it  will  not 
relieve  the  pain  of  a  bony* inflammation.  To  decrease  the  con- 
gestion and  relieve  the  pain  of  an  osteomyelitis  or  mastoiditis 


6  If  it  be  argued  that  the  elastic  bandage  should  be  so  lightly  applied  as  to  produce  no 
retardation  of  the  blood  flow  or  any  duskiness  of  the  skin,  then  we  may  ask  how  it  has 
produced  any  change  whatsoever,  for  it  certainly  could  not  hasten  the  circulation.     Such 
a  method  for  the   sustaining   of  a  therapeutic  hypothesis  is  closely  akin  to  the  homeo- 
pathic dogma  of  increasing  potentiality  from  infinite  dilution. 

7  There  is  only  one  organ  in  which  passive  congestion,  i.  e.,  the  retarding  of  the  blood 
current  can  possibly  result  in  an  "arterial"  hyperemia.    This  organ  is  the  lung.     In  the 
nature  of  the  case  any  retarding  of  the  outflow  of  the  blood   from  the  lungs  only  re- 
sults in  increasing  the  amount  of  their  oxygenated  blood.    This  fact  probably  accounts 
for  the   relative  infrequency   of  pulmonary  tuberculosis  accompanying  valvular  heart 
disease. 

8  Meyer  and  Schmieden— Bier's  Hyperemic  Treatment,  1909,  p.  23. 


224  ANTIPHLOGISTIC  EFFECTS 

most  effectually,  the  ice  bag-  must  be  placed  over  the  trunk  of 
the  large  artery  supplying  the  inflamed  part  and  not  over  the 
part  itself,  while  heat  is  applied  directly  to  the  inflamed  part. 
Ice  applied  over  an  inflammation  confined  in  bony  walls  usu- 
ally increases  the  pain,  while  heat  decreases  it.  Neither  will  the 
ice  bag  or  cold  compress  relieve  the  pain  of  an  abscess  even  in 
soft  tissue,  or  only  to  a  slig-ht  degree,  lasting  only  while  the 
treatment  continues.  This  very  fact  is  of  diagnostic  import- 
ance. It  is  presumptive  evidence  that  the  inflammation  has 
gone  on  to  suppuration  and  must  be  opened.  It  should  then 
be  treated  by  hot  applications  to  hasten  the  process  and  localize 
the  abscess  preparatory  to  drainage. 

Not  infrequently  in  the  use  of  physiologic  therapy  the  symp- 
tomatic response  to  a  given  measure  is  of  material  help  in 
diagnosis.  This  may  be  either  in  differential  diagnosis,  as  in 
the  case  of  the  diagnostic  bath  in  typhoid  fever  or  in  suggest- 
ing the  location  or  stage  of  a  pathologic  process  as  in  the  cases 
just  cited. 


CHAPTER  XIX 
THE  TREATMENT  OF  INFLAMMATIONS 

INFLAMMATIONS  OF  THE  EYE 
Iritis,  Keratitis,  Conjunctivitis,  Dachryocystitis,  Ophthalmia 

BECAUSE  of  the  situation,  it  is  necessary  to  use  more  cold 
than  heat  in  treating"  these  inflammations,  since  long-  hot 
applications  to  the  head  produce  cerebral  congestion.  The  cold 
application  may  be  made  by  means  of  compresses  of  four  to  six 
thicknesses  of  gauze  wrung  out  of  ice  water  or  kept  on  a  block 
of  ice.  The  compresses  should  be  applied  almost  continuously, 
being-  renewed  as  frequently  as  warmed,  which  means  every 
two  or  three  minutes.  A  more  convenient  and  satisfactory 
method  of  applying  continuous  cold,  and  one  which  saves  much 
time,  is  the  ice  water  coil.  This  is  a  coil  about  three  inches  in 
diameter  (Fig.  5/.).  It  is  made  of  very  small  rubber  tubing 
with  a  lumen  of  about  2  mm.  Ice  water  should  be  kept  in  the 
irrigating-  can  and  pieces  of  ice  in  the  receptacle  for  the  outflow 
so  that  the  irrigating  can  may  be  filled  from  the  outflow  as 
soon  as  empty.  It  may  be  necessary  to  use  a  hot  gauze  com- 
press occasionally,  often  enough  to  renew  the  reactive  ability 
and  make  the  cold  comfortable  and  acceptable  to  the  patient. 
Brief  applications  of  the  fomentation  may  be  used  over  the  side 
of  the  face  to  secure  derivation,  or,  with  a  small  piece  of  ice 
wrapped  in  gauze  applied  over  the  eye  itself,  a  larger  fomenta- 
tion may  be  applied  so  as  to  cover  the  eye,  forehead,  and  cheek. 
In  all  cases,  the  hot  applications  should  be  of  short  duration. 
After  the  acuteness  of  the  inflammation  subsides,  small  gauze 
fomentations  may  be  used  alternately  with  the  cold  compress, 
the  heat  being  used  for  a  shorter  time  than  the  cold.  It  is 
usually  necessary  to  renew  the  compresses  about  every  two 

15  (225) 


TREATMENT  OF  INFLAMMATIONS 

minutes.  The  results  are  apparent  in  the  relief  of  the  conges- 
tion, inflammation,  and  pain.  In  ecchymoses  about  the  eye 
the  revulsive  compress  should  be  used. 

In  the  inflammations  mentioned  above,  the  appropriate  anti- 
septic treatment,  the  use  of  silver  salts,  etc.,  should  be  followed 


Fig.  51.    Apparatus  for  treating  inflammations  of  the  eye. 

just  as  carefully  as  otherwise,  and  in  iritis  dilatation  of  the 
pupil  should  be  secured  by  means  of  atropine.  The  ice  water 
coil  should  also  be  applied  to  the  eye  after  operation  for  tra- 
coma. 

Glaucoma,  Toxic  Amblyopia 

Localized  disturbances  in  the  eye  dependent  upon  systemic 
diseases  may  be  greatly  benefited  by  hydrotherapeutic  treat- 


ERYSIPELAS  227 

ment.  In  glaucoma  the  following-  treatment  gives  relief  by 
reducing  the  vascular  tension.  For  a  period  of  about  thirty 
minutes  give  a  hot  foot  bath  or  hot  leg  bath  together  with  ice 
bags  over  the  carotids  or  apply  the  ice  cravat.  Conclude  the 
treatment  by  a  vigorous  cold  mitten  friction  to  the  legs  or  the 
alternate  hot  and  cold  percussion  douche  to  the  feet,  keeping 
the  ice  over  .the  carotids  until  its  completion.  During  the 
period  of  highest  tension  full  hot  baths  and  other  heavy  sweat- 
ing treatments  must  be  discarded. 

In  toxic  amblyopias,  such  as  tobacco  blindness  and  similar 
affections,  sweating  treatments  combined  with  tonic  measures 
are  indispensable.  The  bowels  should  be  kept  open  by 
enemata,  abdominal  massage  and  a  laxative  diet,  especially  by 
the  use  of  fruit.  An  occasional  saline  cathartic  may  be  nec- 
essary. 

ERYSIPELAS 

After  discussing  the  antiseptic  treatment  of  erj^sipelas,  Osier 
says,  "  Perhaps  as  good  an  application  as  any  is  cold  water, 
which  was  highly  recommended  by  Hippocrates."  During  the 
first  few  hours,  the  ice  bag  should  be  used  continuously  over 
the  topical  application.  The  ice  bag  is  used  throughout  this 
disease  more  than  in  other  inflammations,  since  new  parts  are 
progressively  involved  and  the  advancing  border  is  therefore  in 
the  acute  stage.  An  occasional  fomentation  may  be  necessary 
to  renew  the  reactive  capacity  of  the  tissues.  In  the  case  of 
meningeal  involvement ,  or  deep  inflammation ,  strong  derivative 
means  should  be  used,  as  a  hip  and  leg  pack  with  the  ice  cap 
over  the  affected  part.  The  latter  should  be  continued  with  but 
little  interruption.  Hot  applications  to  the  head  only  tend  to 
increase  the  deep  congestion.  In  the  case  of  erysipelas 
migrans,  very  hot  fomentations,  or  alternately  applied  extreme 
hot  and  cold,  give  the  best  results.  These  should  not  be  used 
on  the  head  or  face,  or  about  the  neck.  The  migratory  form 
usually  affects  the  skin  of  the  trunk  or  limbs. 

OTITIS  MEDIA— ACUTE  SUPPURATIVE 

These  cases  rarely  present  themselves  early  enough  to  abort 
the  formation  of  pus  unless  they  come  on  the  first  indication  of 


228  TREATMENT  OF  INFLAMMATIONS 

the  closure  of  the  Eustachian  tube.  The  pain  of  catarrhal  otitis 
and  aural  neuralgias  is  best  relieved  by  fomentations.  After 
hot  treatment,  the  patient  should  be  unusually  careful,  since  he 
is  rendered  more  susceptible  to  colds.  If  it  seems  probable  that 
rupture  of  the  drum  may  be  prevented,  or  while  waiting  to  do 
paracentesis  tympani,  the  following'  treatment  may  be  used: 
Direct  the  patient  to  take  a  hot  foot  bath,  or  better,  a  leg  bath, 
with  fomentations  over  the  ear  and  side  of  the  face,  cold  com- 
presses being  used  to  the  neck  and  opposite  side  of  the  head. 
In  adults  the  ice  cravat,  or  ice  bag  to  the  carotid  of  the  same 
side  may  be  used.  This  derivation  will  reduce  the  congestion 
and  partially,  or  entirely,  relieve  the  pain.  It  may  also  lessen 
the  liability  to  rupture  of  the  drum. 

Otherwise,  the  condition  should  be  treated  according  to  plans 
outlined  in  any  standard  text  on  diseases  of  the  ear.  The  use  of 
hot  air  deserves  mention  as  a  most  efficient  means  in  both  acute 
and  chronic  suppurative  otitis  media. 

ACUTE  MASTOIDITIS 

Those  cases  which  tend  toward  recovery,  that  is,  where  the 
inflammation  does  not  go  beyond  turgescence  and  congestion  of 
the  lining  membrane  of  the  mastoid  cells,  may  be  aided  to  an 
uneventful  recovery  by  the  use  of  fomentations  to  the  mastoid, 
dry  heat,  and  derivation.  In  infants  and  younger  children,  the 
Leiter  coil  with  ice  water  or  the  ice  bag  may  be  used  over  the 
mastoid.  At  this  age  mastoid  periostitis  is  very  common, 
which  condition  is  always  benefited  by  the.  cold  coil.  In  older 
children  and  adults  we  have  not  been  able  to  use  cold  over  the 
mastoid  because  of  the  pain  occasioned  by  it. 

In  many  cases  the  pain  may  be  relieved  by  strong  derivative 
means,  as  a  very  hot  leg  bath  and  fomentations  to  the  mastoid, 
with  the  ice  cravat  or  an  ice  bag  to  the  carotid  of  the  same  side. 
This  should  be  continued  from  twenty  or  thirty  minutes  to  an 
hour  and  finished  with  a  vigorous  cold  mitten  friction  to  the 
limbs  and  trunk.  We  have  found  this  plan  very  successful  in 
obviating  the  necessity  for  large  doses  of  hypnotic  drugs  in 
those  cases  which  refuse  operation,  or  while  preparations  are 
being  made  for  surgical  interference. 


-ACUTE  TONSILLITIS  229 

ALVEOLAR  ABSCESS 

This  condition  should  be  treated  on  precisely  the  same  prin- 
ciples as  mastoiditis,  always  bearing  in  mind  that  the  cure  lies 
in  securing:  drainage  as  promptly  as  possible ,. 

SIMPLE  PHARYNGITIS 

The  soreness  of  the  throat  is  most  effectually  relieved  by 
large  fomentations  to  the  throat,  coming  well  up  under  the  jaw 
and  back  to  the  ears.  If  there  is  much  fever,  a  mild  sweating 
treatment  will  be  beneficial  at  the  beginning.  This  may  be 
accomplished  by  a  hot  foot  bath  with  the  fomentation  to  the 
throat,  or  an  electric  light  bath.  The  treatment  should  be  con- 
cluded with  a  cold  mitten  friction,  and  a  heating  compress 
applied  to  the  throat  to  be  left  over  night.  The  next  day,  use 
the  hot  foot  bath  and  revulsive  compress  to  the  throat.  Each 
hot  treatment  should  be  concluded  with  some  tonic  measure, 
such  as  the  cold  mitten  friction,  cold  towel  rub,  graduated  or 
hot  and  cold  spray.  It  may  be  necessary  to  fepeat  the  hot  foot 
bath  and  revulsive  compress  two  or  three  times  a  day,  always 
leaving  the  heating  compress  in  place  between  treatments  and 
over  night.  This  latter  measure  is  more  important  than  any 
other  in  the  treatment  of  sore  throat.  The  inhalation  of  steam 
and  gargling  of  hot  water  will  aid  in  relieving  the  pain.  Or- 
dinary antiseptic  throat  gargles  in  hot  water  should  also  be  used. 

ACUTE  TONSILLITIS 

The  temperature  is  usually  very  high,  but  of  a  transient  type. 
It  is  unnecessary  to  employ  antipyretic  measures.  In  fact, 
general  applications  of  cold  are  quite  likely  to  produce  chilling. 
At  the  beginning  of  treatment,  the  patient  should  be  given 
some  sweating  measure,  such  as  a  hot  leg  pack,  full  blanket 
pack,  or  hot  leg  bath  with  fomentations  to  the  throat  and  ice 
compress  or  ice  cap  to  the  top  and  sides  of  the  head.  Because 
of  the  rapid  pulse  and  extreme  prostration,  an  ice  bag  should 
be  applied  to  the  heart.  The  patient  may  be  taken  out  with  a 
cold  mitten  friction,  or,  if  able  to  stand,  a  graduated  shower. 
A  well  covered  heating  compress  should  be  applied  to  the  neck. 
After  the  initial  treatment,  fomentations  or  the  revulsive  com- 


£30  TREA  TMENT  OF  INFLAMMA  TIONS 

press  should  be  applied  to  the  neck  at  frequent  intervals,  always 
following-  them  by  the  heating-  compress.  In  perhaps  the 
majority  of  cases  and  always  in  severe  tonsillitis  with  high 
fever,  it  is  better  to  apply  ice  bag's  over  the  tonsillar  area  at 
the  sides  of  the  neck.  These  will  also  cover  the  carotid  arteries 
and  may  be  kept  on  almost  continuously.  Throughout  the 
disease,  very  vigorous  tonic  treatment  may  be  employed.  The 
cold  mitten  friction,  or  cold  towel  rub,  wet  sheet  pack,  etc., 
have  been  found  useful  in  maintaining  the  vitality  of  the  patient. 
In  case  of  quinsy,  the  paratonsillar  abscess  should  be  lanced 
at  the  proper  time.  Previous  to  this,  fomentations  frequently 
repeated  will  aid  in  hastening-  suppuration,  localizing-  the 
abscess  and  making  more  apparent  the  pointing-.  Occasionally 
in  those  subject  to  attacks  of  quinsy,  the  early  and  continuous 
use  of  the  ice  bag  may  prevent  abscess  formation. 

BOILS  AND  CARBUNCLES 

In  the  beginning,  while  the  boil  is  only  a  pimple,  it  may  be 
aborted  by  the  prolonged  use  of  ice  over  it,  with  a  fomentation 
covering  it  and  a  larger  area,  applied  at  the  same  time.  The 
use  of  extreme  hot  and  cold  applications,  alternately  applied 
(fluxion),  is  also  an  advantage.  When  it  is  no  long-er  possible 
to  stop  the  progress  of  the  boil,  fomentations,  poultices,  heating- 
compresses,  etc.,  may  be  used  to  relieve  the  pain  and  hasten 
the  localization  of  the  pus.  It  should  then  be  lanced.  The 
absorption  of  the  indurated  residue  about  the  boil  may  be  hast- 
ened by  hot  and  cold  applications,  such  as  fomentations  and  ice 
or  the  alternate  hot  and  cold  pour.  Pressure  about  the  boil,  or 
friction  to  the  skin  should  be  avoided,  as  these  measures  tend 
to  spreading  of  the  bacteria  and  the  infection  of  other  areas. 

ACUTE  BLOOD  POISONING 

Septicemia  of  Hand,  Foot,  Etc.  These  infections  are  usually 
occasioned  by  scratches,  cuts,  bruises,  thorns,  etc.  While  the 
initial  lesion  may  seem  to  be  trivial,  serious  results  follow  very 
quickly.  For  this  reason,  blood  poisoning  should  be  treated 
most  vigorously.  The  object  to  be  accomplished  is  the  increas- 
ing of  phagocytosis  and  so  increasing  the  circulation  as  to  rapidly 


SEPTICEMIA  231 

renew  the  blood  flowing-  through  the  infected  part.  When 
first  seen  by  the  physician,  the  inflammation  has  usually  gone 
beyond  the  primary  stage.  In  the  case  of  the  hand,  the  part 
is  very  much  swollen,  blue,  and  edematous.  Extension  of  the 
infection  is  indicated  by  red  lines  (lymphangitis)  extending 
upward,  and  by  swelling  and  tenderness  of  the  regional  lym- 
phatics. When  this  occurs,  most  prompt  and  vigorous  measures 
are  necessary.  The  following  treatment,  if  applied  reasonably 
early,  has,  in  the  writer's  experience,  never  failed  of  success: — ' 

Provide  two  pails,  foot  tubs,  or  other  receptacles,  sufficiently 
large  to  immerse  the  infected  part.  {Plate  XL} .  One  of  these 
should  be  filled  with  the  hottest  water  that  can  be  borne,  more 
being  added  from  time  to  time  to  the  limit  of  toleration.  The 
other  pail  should  be  filled  with  ice  water,  containing  pieces  of 
ice.  The  patient  is  instructed  to  immerse  the  part  in  the  hot 
water  for  two  minutes,  then  in  the  cold  for  fifteen  to  thirty  sec- 
onds, after  which.it  is  returned  to  the  hot  water  again  for  one 
and  one-half  or  two  minutes,  then  reimmersed  in  the  cold  for 
fifteen  to  thirty  seconds.  These  changes  are  kept  up  for  at 
least  ha]f  an  hour  and  repeated  from  two  to  four  or  five  times  a 
day,  according-  to  the  seriousness  of  the  infection.  If  thought 
best,  disinfectants  may  be  added  to  both  the  hot  and  cold  water. 
We  'have  used  crystals  of  potassium  permanganate  in  one  and 
oxalic  acid  crystals  in  the  other. 

It  may  be  necessary  to  lance  the  part  if  there  are  signs  of 
suppuration.  This  should  be  done  anyway  if  the  infection  has 
stood  some  time  without  treatment,  or  if  extreme  swelling-  and 
edema  exist.  In  the  latter  case,  multiple  openings  may  be 
necessary.  Massag-e  should  be  avoided  altogether,  as  it  spreads 
the  bacteria  along-  the  lymph  channels. 

Cases  treated  as  outlined  above  require  only  a  few  days  for  a 
complete  cure,  while  cases  treated  by  poulticing,  antiseptics, 
incisions,  without  hydrotherapy,  usually  run  a  course  of  from, 
ten  days  to  a  month,  or  even  longer.  Some  cases  of  gangrene 
are  successfully  treated  by  this  method.  The  appearance  of 
the  line  of  demarkation  may  be  hastened  by  the  use  of  alter- 
nate hot  and  cold  applications. 

Chronic  cases  of  osteomyelitis,  with  much  riddling  of  the  bone 


2S2  TREATMENT  OF  INFLAMMATIONS 

and  soft  parts,  with  sinuses,  sequestrum  formation,  etc.,  are 
successfully  treated  along  the  same  lines.  The  use  of  von 
Mosetig's  bone-wax  followed  by  the  alternate  hot  and  cold  pour, 
applied  daily,  gives  good  results. 

POISON  IVY  AND  OAK 

These  inflammations  require  some  active  antiseptic  treat- 
ment. In  the  earlier  stages,  continuous  cold  compresses,  or 
•the  ice  bag  may  be  used  with  benefit.  Later  on,  vigorous  hot 
and  cold  compresses,  pours,  or  sprays  give  the  best  results. 
This  latter  means  has  proven  of  inestimable  value  in  long- 
standing, refractory  cases. 

PNEUMONIA 

Pneumonia  is  an  acute,  self-limited  infectious  disease  char- 
acterized by  a  general  toxemia  and,  pathologically,  by  a  definite 
series  of  changes  in  the  lungs.  The  first  stage  is  that  of 
intense  pulmonary  congestion.  In  the  second  stage,  there  is 
exudation  into  the  alveoli,  so  that  the  affected  lobe  becomes 
consolidated,  the  condition  being  known  as  red  hepatization. 
The  third  stage — gray  hepatization — is  marked  by  the  changes 
accompanying  resolution.  The  clinical  feature  of  the  crisis 
marks  the  transition  from  the  second  to  the  third  stage  and. the 
beginning  of  resolution.  Clinically,  the  following  symptoms 
are  prominent:  pain  in  the  chest,  dyspnoea,  with  rapid  respira- 
tion, more  or  less  cyanosis,  and  cough  accompanied  by  the 
expectoration  of  "prune-juice"  or  "rusty"  sputum.  Pneu- 
monia runs  a  short  course  and,  if  the  resistance  of  the  patient 
is  sufficient,  antitoxines  are  produced  quite  rapidly,  so  that  the 
progress  of  the  infection  is  arrested.  It  should  be  recognized 
that  pneumonia  is  a  general  infection,  much  like  typhoid,  and 
therefore  demands  systemic  treatment. 

.  The  greatest  danger  in  pneumonia  arises  from  two  causes 
principally, —  (l)  deficient  aeration  of  the  blood  and  (2)  failure 
of  the  circulation.  The  air  hunger  is  manifest  by  the  rapid 
respiration,  dyspnoea,  and  cyanosis.  In  all  febrile  conditions 
there  is,  on  the  part  of  the  tissues,  a  lessened  capacity  for  the 
absorption  of  oxygen.  In  pneumonia,  beside  this,  the  lung 


PLATE  XI.     Alternate  hot  and  cold  immersion  for  infection  of  the  hand. 


PNEUMONIA  233 

area  for  gaseous  interchange  is  very  much  limited  because  of 
the  consolidation.  The  stasis  of  the  blood  in  the  lungs  tends 
to  increase  the  difficulty.  The  right  heart  is  particularly 
embarrassed  because  of  the  lung  consolidation  and  the  pulmon- 
ary stasis.  It  has  difficulty  in  forcing  a  sufficient  amount  of 
blood  through  the  lungs  to  provide  the  tissues  with  the  proper 
amount  of  oxygen.  There  is  increased  pressure  in  the  right 
ventricle,  as  evidenced  by  the  accentuated  second  pulmonic 
sound.  The  absence  of  this  sign  is  one  of  the  evidences  of 
failure  of  the  right  heart  and  dilatation  of  the  right  ventricle. 

In  those  cases  due  to  alcohol,  the  blood-vessels  are  in  a  state 
of  passive  dilatation  from  paresis  of  the  vasomotors.  Both  the 
capillary  vessels  of  the  lungs  and  those  of  the  general  periphery 
are  in  this  condition.  It  is  because  of  this  paretic  condition 
of  the  vessels  and  the  failure  of  the  narcotized  cutaneous 
nerves  to  appreciate  the  danger  from  cold  that  retrostasis  is 
so  likely  to  occur.  Pneumonia  is  especially  fatal  in  alcoholics. 
There  should  be  a  high  leucocytosis.  The  absence  of  this  is 
one  of  the  unfavorable  signs. 

From  the  foregoing,  we  may  select  four  indications  of  prime 
importance  in  the  treatment  of  pneumonia.  1.  Increase  the 
aeration  of  the  blood.  2.  Sustain  the  heart  and  circulation. 
3.  Increase  leucocytosis  and  phagocytosis  in  order  to  combat 
the  infection.  4.  Decrease  toxemia. 

Treatment 

Pneumonia  as  such  does  not  exist  until  the  stage  of  exuda- 
tion and  consolidation.  The  pulmonary  congestion,  however 
intense,  does  not  constitute  pneumonia,  although  if  pneumococci 
are  present,  it  is  quite  likely  to  end  in  consolidation.  It  is  im- 
possible to  abort  pneumonia  after  the  exudation  has  occurred, 
although  it  is  possible,  by  strong  derivative  means,  to  reduce 
even  a  very  intense  pulmonary  congestion.  The  presence  of 
numerous  crepitant  rales  is  not,  in  itself,  evidence  of  consolida- 
tion. The  rales,  together  with  rapid  respiration,  pain,  and 
fever,  may  be  present  in  the  stage  of  congestion  before  exuda- 
tion has  occurred.  If  treatment  can  be  begun  very  early,  even 
though  there  is  no  positive  assurance  that  the  condition  is  not 


TREATMENT  OF  INFLAMMATIONS 

more  than  a  congestion ,  it  is  best  to  employ  some  derivative 
or  sweating-  treatment  in  order  to  reduce  as  much  as  possible 
the  pulmonary  congestion.  The  collateral  heat  may  be  either 
a  very  hot  leg:  bath,  a  hot  hip  and  leg-  pack,  or  full  blanket 
pack.  The  latter  will  be  best  if  the  patient  is  very  chilly. 
These  measures  should  be  reenforced  by  the  drinking-  of  some 
hot  liquid  to  produce  perspiration  and  thus  aid  in  reducing-  the 
internal  congestion.  In  applying  the  cold  to  the  chest,  it  must 
be  borne  in  mind  that  the  lobes  affected  are  usually  the  lower 
lobes  and  present  the  greater  surface  at  the  sides  and  back  of 
the  chest.  Over  this  area  may  be  used  a  very  large  ice  cap  or 
ice  pack.  This  should  not  be  placed  until  the  patient  is  we'l 
warmed,  since  otherwise  it  may  produce  chilliness.  The 
collateral  heat  and  local  cold  should  be  continued  until  effectual 
derivation  is  secured.  If  this  requires  a  very  long  time,  the 
pack  must  be  reenforced  by  hot  water  bottles,  bricks,  etc.,  and 
the  cold  over  the  affected  lobe  replaced  for  a  short  time  by  a 
very  hot  fomentation  to  renew  the  nerve  sensibility  and 
promote  the  vigor  of  the  reflex  effect  from  the  cold.  It  is  well 
to  use  the  ice  bag  over  the  heart  if  the  pulse  is  very  rapid. 
Treatment  may  be  concluded  with  a  cold  mitten  friction.  A 
very  short  fomentation  may  be  applied  to  the  chest,  followed 
by  a  heating  compress  or  a  moist  chest  pack  wrhich  should  be 
left  in  place  until  the  next  treatment. 

The  supplying  of  plenty  of  fresh  cold  air  is  of  prime  import- 
ance. It  has  been  stated  that,  during  the  late  war,  cases  of 
pneumonia  treated  in  tents  in  the  most  rigorous  weather  did  far 
better  than  those  treated  in  hospital  buildings.  The  open  air 
treatment  as  carried  out  in  some  hospitals  has  greatly  reduced 
the  mortality.  The  laity  fear  the  effects  of  cold  air  in  this 
disease,  believing  that  the  patient  is  likely  to  take  cold  and  so 
the  pneumonia  be  made  worse.  Persons  with  fever  are  not 
likely  to  suffer  from  an  "overdose"  of  cold  air.  For  the 
reason  stated  above,  it  is  very  necessary  that  the  lungs  be 
supplied  with  the  greatest  possible  amount  of  pure  fresh  air. 
Neither  should  the  air  be  warmed.  The  depth  of  respiration  is 
stimulated  by  the  cold.  All  the  cold  treatments  given  in  the 
hydriatic  management  of  pneumonia  increase  the  depth  of 


PNEUMONIA 


235 


respiration  and  so  enable  the  body  to  make  use  of  the  oxygen 
supplied  by  the  fresh  air.  This  is  true  of  the  cold  compress, 
the  heating"  compress,  the  ice  pack  and  cold  rubs  and  frictions. 
If  it  is  not  possible,  because  of  the  season,  to  obtain  very  cold 
air,  much  might  be  saved  in  the  mortality  by  providing  means 
of  refrigerating  the  air  supplied  to  the  patient.  The  air  may 
be  supplied  through  a  hood  fitted  into  the  opening  made  by 
raising  the  lower  sash  of  any  ordinary  window  {Fig.  52.) .  The 
other  end  of  the  hood  should  fit  down  over  the  head  of  the 


Fig..  52.    The  window  tent  for  the  fresh  air  treatment  of  fevers. 

patient  and  can  be  tucked  in  about  the  pillow,  coming  no  lower 
than  just  under  the  chin.  This  may  be  arranged  with  glass 
windows  so  as  to  obviate  the  necessity  of  removing  the  hood 
for  observation  of  the  patient,  etc.  Those  who  have  lived  in 
the  Arctic  regions,  Labrador  and  other  very  cold  climates,  tell 
us  that  pneumonia  and  tuberculosis  are  rare  diseases  there  and 
in  some  places  almost  unknown. 

Relative  to  the  beneficial  effects  of  fresh  air  in  febrile 
diseases,  the  following  is  related  of  Dr.  Alonzo  Clarke: — 

It  is  interesting  to  read  how  he  managed  typhus  fever  in 
Belle vue  Hospital.  There  were  two  hundred  fifty  cases  con- 


236  TREATMENT  OF  INFLAMMATIONS 

stantly  under  his  care,  and  as  many  more  under  the  care  of 
his  colleagues.  The  mortality  was  great.  Precautions  against 
the  draughts  of  air,  for  fear  of  pneumonia,  were  carefully 
adopted.  Doctor  Clarke,  not  having  this  dread,  ordered  that 
there  should  be  the  freest  ventilation,  with  scrupulous  cleanli- 
ness. Although  it  was  winter,  the  windows  were  removed, 
stoves  were  placed  before  the  open  spaces  to  raise  the  tempera- 
ture of  the  incoming  air,  clothing  was  increased,  stimulants 
were  given  in  moderate  quantities,  and  other  medicine  mostly 
dispensed  with.  Of  the  two  hundred  fifty  cases  not  a  death 
occurred  in  the  period  of  a  fortnight.  In  two  weeks  they  were 
convalescent.  In  other  wards  of  the  hospital  where  the  man- 
agement was  unchanged,  the  mortality  was  undiminished. 

Sir  William  Osier  says,1  "death  is  most  frequently  due  to 
the  action  of  the  poisons  on  the  vasomotor  centers,  with  pro- 
gressive lowering  of  the  blood  pressure."  "An  all  important 
indication  is  to  support  the  circulation.  Hydrotherapy  and  keep- 
ing the  patient  out  of  doors  are  of  great  value  for  this." 

The  sustaining  of  the  heart  and  circulation  is  best  accom- 
plished by  judicious  hydrotherapy.  Romberg  and  Passler  have 
shown  that  the  toxic  albuminoid  produced  by  the  pneumococcus 
paralyzes  the  vasomotor  center  in  the  medulla,  and  Passler 
regards  this  as  the  most  common  cause  of  death  in  pneumonia 
as  far  as  the  circulation  is  concerned.  Vasomotor  tonics  are  as 
essential  in  pneumonia  as  in  other  febrile  diseases  and  the 
effect  of  hydrotherapy  as  a  vasomotor  stimulant  is  its  most 
important  asset  in  this  disease.  Hand  in  hand  with  this  effect 
goes  stimulation  of  respiration  and  of  the  heart  itself.  The 
cold  compress  to  the  chest  is  applicable  in  all  cases.  An  ordi- 
nary linen  towel  or  hand  towel  may  be  used  for  this  purpose, 
two  or  three  thicknesses  of  cloth  usually  being  sufficient..  It 
should  be  wrung  from  ice  water  and  applied  to  the  front  and 
sides  of  the  chest  and  covered  with  a  flannel  cloth.  If  desired 
to  greatly  stimulate  respiration  and  the  heart  action,  it  should 
be  frequently  renewed.  In  ordinary  cases,  it  may  be  left  on 
fifteen,  twenty,  or  thirty  minutes  at  a  time.  While  the  patient 
is  sleeping,  or  when  it  is  desired  to  give  rest,  the  compress 

1    Principles  and  Practice  of  Medicine.  Eighth  Edition. 


PNEUMONIA  237 

should  be  left  on  an  hour  or  two.  It  then  becomes  a  heating 
compress. 

The  square  or  roller  chest  pack  is  an  excellent  means  of 
applying  the  principles  of  the  heating-  compress.  It  has  the 
advantage  of  the  heating  compress  in  that  a  greater  area  is 
treated  and  undue  circulation  of  the  air  about  the  wet  cloth 
more  perfectly  prevented.  It  should  be  left  in  place  two  or 
three  hours,  or  may  be  put  on  and  left  over  night,  unless 
necessary  to  give  other  treatments. 

In  case  of  strong,  vigorous  men,  it  is  possible  to  use  with 
benefit  the  ice  pack  to  the  chest.  The  ice  pack  may  be  applied 
by  means  of  several  ice  bags  adjusted  to  cover  the  skin  surface 
over  the  affected  lobe,  or  it  may  be  made  by  placing  cracked  ice 
in  a  Turkish  towel  and  covering  the  whole  with  oiled  silk  or 
gossamer  cloth  so  as  to  prevent  wetting  the  clothing  and  bed- 
ding. These  packs  may  be  left  in  place  almost  continuously, 
applying  every  thirty  minutes  or  every  hour  one  or  twro  short 
fomentations;  and  every  three  or  four  hours,  replacing  the  pack 
by  the  heating  compress,  allowing  the  latter  to  remain  thirty 
minutes  or  an  hour.  The  ice  pack  should  not  be  used  where 
the  patient  is  inclined  to  be  chilly,  or  with  thin  patients  and 
those  of  low  vitality.  Whenever  it  is  used,  the  limbs  should  be 
kept  warm  by  the  use  of  hot  water  bottles.  It  is  well  also  to 
give  a  hot  foot  bath  or  leg  pack  at  intervals  of  five  or  six 
hours.  The  cold  compress  wrung  from  water  at  50° — 60°  and 
applied  to  the  chest  every  thirty  minutes  is  better  than  the  ice 
pack  in  most  cases.  It  should  be  covered  with  flannel  so  as  to 
become  a  heating  compress  before  renewal.  Such  applications 
changed  every  hour  are  highly  recommended  by  Osier. 

The  cold  mitten  friction  and  the  cold  towel  rub  are  invaluable 
in  aiding  the  circulation  and  sustaining  the  heart.  It  may  be 
necessary  where  there  is  cold  clammy  perspiration,  chilliness, 
or  cyanosis,  to  precede  the  cold  treatment  by  short  fomenta- 
tions applied  to  the  limb  or  part  just  previous  to  the  cold 
mitten  friction.  If  the  heart  is  very  much  embarrassed,  it 
may  be  greatly  relieved  and  the  patient  tided  over  a  crisis  by 
the  use  of  short  hot  applications  as  just  mentioned,  and  imme- 
diately succeeded  by  the  cold  mitten  friction  given  until  the 


2S8  TREATMENT  OF  INFLAMMATIONS 

skin  is  red  and  reaction  complete.  The  part  should  then  be 
very  rapidly  dried  with  a  rough  towel.  Dry  friction  and 
percussion  should  follow  in  order  to  secure  thoroug-h  reaction. 
There  are  two  principles  involved  in  this  method, —  first, 
the  stimulation  of  the  peripheral  circulation  so  as  to  relieve 
the  heart  of  its  added  burden;  and  second,  because  of  the 
tonic  dilatation  of  the  surface  vessels,  there  is  produced  a  very 
decided  and  lasting  derivation,  so  that  the  extreme  engorge- 
ment of  the  heart  and  lungs  is  relieved. 

A  warm  bath  at  98°  or  100°  gradually  cooled  to  90°  is  highly 
recommended  by  some.  The  effect  of  this  treatment  may  be 
very  much  increased  by  allowing  the  patient  to  remain  just 
long  enough  to  secure  a  thorough  warming,  cold  applications 
to  the  head  and  heart  being  kept  in  place  during  this  time. 
The  patient  then  sits  up  while  .he  receives  to  the  chest, 
shoulders,  and  back  two  to  four  affusions  of  water  at  90°.  This 
stimulates  respiration  and  increases  the  efficiency  of  expec- 
toration. If  such  tub  baths  are  to  be  used  in  pneumonia,  it 
must  be  only  in  well  selected  cases  and  certainly  only  in  mild 
cases  without  high  fever  or  dyspnosa. 

Some  have  very  highly  recommended  the  Brand  bath  in 
lobar  pneumonia.  We  can  see  no  advantage  in  this  measure 
over  the  others  mentioned  and  can  readily  understand  that  in 
many  cases  it  might  prove  dangerous,  as  the  heart  and  lungs 
are  unable  to  withstand  the  retrostasis  occasioned  by  the  initial 
anemia  of  the  skin,  which  follows  contact  with  the  cold  water. 
In  general,  it  may  be  said  that  full  tub  baths  are  not  applicable 
in  pneumonia. 

Pain.  The  pain  in  pneumonia  is  due  chiefly  to  the  accom- 
panying pleurisy.  The  inflammation  is  largely  on  the  side  of 
the  visceral  layer  and  so  does  not  contraindicate  the  use  of  cold 
applications.  Pain  is  perhaps  best  relieved  by  the  use  of  fomen- 
tations. These  should  be  large  enough  to  cover  an  entire 
side  of  the  chest  and  are  more  efficient  when  applied  from  spine 
to  sternum  with  the  patient  lying  on  the  opposite  side.  The 
chest  pack  or  heating  compress  should  follow  the  hot  treatment. 

Cough  and  Expectoration.  All  of  the  treatments  recommended 
above  are  beneficial  in  aiding  the  expulsion  of  mucus.  A  severe 


PNEUMONIA  239 

cough  may  be  relieved  by  the  use  of  fomentations  and  the 
heating"  compress.  Inhalations  of  steam  are  also  beneficial. 
The  revulsive  compress  is  perhaps  the  most  efficient  means  in 
stimulating-  expectoration.  A  large  fomentation  is  first  applied; 
as  soon  as  the  heat  begins  to  subside,  it  should  be  replaced  by 
a  towel  wrung  from  ice  water.  This  should  be  left  on  until  it 
has  become  slightly  heated,  perhaps  one  to  three  minutes. 
The  part  should  be  dried  and  the  second  fomentation  applied. 
Three  or  four  changes  are  usually  sufficient  to  accomplish  the 
desired  result.  A  revulsive  compress  also  stimulates  the  heart 
and  increases  the  depth  of  respiration  and  the  consequent 
aeration  of  the  blood. 

The  patient  should  drink  large  quantities  of  water  by  taking 
it  frequently  in  small  amounts.  This  increases  diuresis  and 
the  elimination  of  toxines.  Either  hot  or  cold  water  may  be 
used  according  to  indications.  The  bowels  should  be  kept  open 
by  salines  and  enemata  as  needed.  A  very  light  diet  low  in 
proteid  also  aids  in  limiting'  the  toxemia. 

Medicinal  Treatment 

Quinine.  So  much  has  recently  been  written  concerning  the 
use  of  large  doses  of  quinine  in  the  treatment  of  pneumonia  that 
no  discussion  of  this  disease  would  be  complete  without  refer- 
ence to  its  effects. 

"It  has  been  suggested  that  its  efficiency  in  fever  is  due  to 
an  antiseptic  action  on  the  blood.  This  is  not  the  case,  since 
bacteria  are  very  resistant  to  it  and  would  not  be  affected  by  it 
in  the  concentration  in  which  it  could  exist  in  the  blood."  It 
does  certainly  reduce  the  temperature  as  we  have -previously 
noted,  but  this  is  not  of  prime  importance  in  pneumonia.  Anti- 
pyresis  is  of  secondary  importance,  nor  do  patients  bear  great 
abstraction  of  heat,  as  is  the  case  in  typhoid  fever.  The  tem- 
perature is  lowered  at  the  expense  of  the  heart's  action  and 
oxygen- carry  ing  capacity  of  the  red  blood  cells.  Both  of  these, 
it  is  necessary  to  sustain  and  enhance  in  pneumonia.  Quinine 
limits  leucocytosis  and  checks  phagocytosis.  If  20  to  30  grains 
are  given  daily,  the  disease  is  likely  to  run  an  atypical  course, 

2    Sollmann— Text   Book  of  Pharmacology,  p.  350. 


g40  TREATMENT  OF  INFLAMMATIONS 

there  being  no  frank  crisis,  which  is  replaced  by  very  much 
delayed  resolution,  the  fever  declining:  by  lysis. 

Moist  rales  may  be  heard  in  the  chest  long-  after  resolution 
should  be  complete.  One  area  will  hardly  more  than  clear  up 
before  another  area  is  involved,  so  that  by  delayed  resolution 
and  reinvolvement  of  another  area,  the  pathology  assumes  a 
sort  of  migratory  type.  Probably  the  reason  for  the  failure  in 
the. appearance  of  the  crisis  is  due  to  the  fact  that  the  sthenic 
condition  has  been  reduced  to  an  asthenia,  the  system  lacking 
sufficient  vitality  to  produce  a  normal  crisis.  Anyone  who  will 
take  the  trouble  to  "read  up"  on  the  effects  of  quinine  will 
soon  be  convinced  of  its  harmfulness  in  pneumonia.  The  caution 
sounded  by  Dr.  W.  C.  Alvarez  in  a  recent  letter  published  in 
the  Journal  of  the  American  Medical  Association  is  certainly 
timely.3  In  a  personal  communication  recieved  from  Doctor 
Alvarez,  he  states  that  among  the  many  letters  he  recieved 
after  the  publishing  of  this  communication  to  the  journal,  one 
came  from  a  fellow  practitioner  who  was  much  in  favor  of 
the  quinine  treatment,  but  had  recently  had,  among  a  small 
series,  seven  bad  cases  of  empyema.  On  the  ordinary  expectant 
plan,  it  should  take  two  hundred  to  four  hundred  cases  of 
pneumonia  to  furnish  seven  of  empyema.  The  white  blood 
cells  were  paralyzed  by  the  quinine  and  so  easily  succumbed 
to  the  infection.  Too  much  can  not  be  said  condemnatory 
of  the  quinine  treatment  of  pneumonia. 

Strychnine.  This  drug  has  been  very  much  vaunted  as  a 
specific  in  meeting  cardiac  incompetency  in  pneumonia.  Much 
to  the  discredit  of  the  profession  generally,  a  plan  frequently 
followed  is  that  of  giving  1-60  grain  of  strychnine  every  three 
hours,  this  being  kept  up  during  the  greater  part  of  the  illness. 
As  some  one  has  said,  "continual  doping  with  strychnine  to 
the  heart  is  like  kicking  a  dying  horse  when  he  is  down."  As 
we  have  already  shown,  the  results  hoped  for  from  strychnine 
are  best  attained  by  proper  hydriatic  means. 

Frank  Billings4  says,  "  Strychnine  and  other  drugs  that  are 
commonly  used  in  failing  left  heart  are  absolutely  valueless 

3  Journal  of  American  Medical  Association,  June  13,  1908.  p.  19%. 

4  Ibid,  October  30,  1909,  p.  1453. 


PNEUMONIA  241 

except  to  stimulate  nerve  centers:  strychnine  will  not  raise  the 
blood  pressure  1  mm.  I  have  used  it  over  and  over  again.  .  .  . 
Finally;,  the  watchful  and  vigilant  care  of  patients  afflicted 
with  pneumonia  without  the  use  of  drugs  is  the  ideal  treat- 
ment." 

Relative  to  the  routine  use  of  digitalis  in  pneumonia  F.  Forch- 
heimer 5  relates  his  experience  following-  the  use  of  large  doses 
as  advised  by  Petresco  of  Bucharest.  He  says  the  "mortality 
was  greater  than  before.  All  the  evil  effects  that  can  be  pro- 
duced by  digitalis  were  noted,  and  after  three  days  of  admin- 
istration of  the  remedy  such  cumulative  effects  were  produced 
as  I  shall  hope  never  to  see  again." 

Alcohol.  When  we  stop  to  think  of  it,  it  must  seem  strange 
.to  any  sane  man  to  suppose  that  a  drug  which  increases  the 
liability  to  pneumonia  and  greatly  increases  its  mortality  should 
ever  be  recommended  as  a  therapeutic  agent  in  that  disease. 
Yet  that  such  has  been  done  is  evidenced  by  the  numerous 
articles  which,  a  few  years  ago,  appeared  in  many  medical 
journals,  recommending  whisky  and  brandy  as  a  routine  treat- 
ment of  pneumonia.  It  is  supposed  that  by  dilating  the  peri- 
pheral vessels,  it  aids  in  decreasing  the  congestion  of  the  lungs. 
This  might  be  the  case,  did  not  alcohol  act  upon  all  the  small 
blood-vessels,  those  of  the  lungs  included.  Neither  is  alcohol 
a  cardiac  stimulant  as  has  more  recently  been  shown  by 
numerous  reliable  experiments.  Experiments  by  Martin  and 
Stevens,  conducted  in  the  Biological  Laboratory  of  the  Johns 
Hopkins  University,  show  that  blood  containing  1-4  of  1  per 
cent  of  alcohol  diminished  within  a  single  minute  the  work 
done  by  the  heart  and  that  in  certain  animals  experimented  on, 
blood  containing  1-2  to  1  per  cent  of  alcohol  so  seriously 
affected  its  working  powers  that  it  was  scarcely  able  to  drive  a 
sufficient  amount  of  blood  to  supply  its  own  nutrient  arteries. 
Doctor  Monroe  of  Glasgow  Royal  Infirmary  says,  "It  has  yet  to 
be  proved  that  the  heart  muscle  can  be  stimulated  by  alcohol." 

In  a  paper  by  E.  Lewis  Backman  before  the  Anti- Alcohol 
Congress  at  Stockholm,  it  was  shown  that  when  a  solution  con- 
taining from  .0025  per  cent  to  .5  per  cent  was  passed  through 

5    Journal  of  American  Medical  Association,  October  30,  1909,  p.  1450. 
16 


242  TREATMENT  OF  INFLAMMATIONS 

the  blood-vessels  of  the  isolated  heart,  in  the  case  of  a  rabbit, 
that  if  the  amount  were  sufficiently  large  to  produce  any 
noticeable  effect,  there  was  manifest  temporary  irregularity  and 
diminution  of  the  strength  of  the  contraction,  or  a  lasting 
arrythmia,  and  a  considerable  reduction  in  the  volume  and  the 
number  of  the  pulsations.  Alcohol  also  limits  or  annihilates 
phagocytic  action. 

John  H.  Musser'6  gives  the  following-  summary  concerning-  the 
treatment  of  pneumonia:  "  In  the  majority  of  the  cases  I  prefer 
to  rely  on  fresh  air,  on  judicious  local  treatment,  on  hydro- 
therapeutics,  on  regulation  of  the  proper  amount  of  food  taken, 
and  particularly  on  care  that  the  patient  is  not  overfed.  I 
watch  carefully  for  the  phenomena  so  well  pictured  by  Doctor 
Forchheimer,  g-uarding"  ag-ainst  the  possibility  of  the  vasomotor* 
syndrome  by  proper  renal  elimination.  Attention  to  proper 
elimination  is  of  the  greatest  importance  in  the  management 
of  the  cases  of  pneumonia,  looking-  toward  the  prevention  of 
cardiac  failure;  in  other  words,  looking-  toward  the  reduction  of 
serious  toxic  symptoms  that  arise  and  have  expression  more 
particularly  in  the  phenomena  just  pointed  out.  To  keep  down 
the  amount  of  food  is  of  the  greatest  importance  in  the  manage- 
ment of  pneumonia  patients.  Watch  carefully  the  state  of  the 
intestinal  tract.  Tympany  is  a  serious  toxic  symptom  in 
pneumonia,  and  its  increase  with  defective  elimination  is  a 
point  that  I  depend  on  as  suggestive  of  the  occurrence  of  vaso- 
motor failure.  This  can  be  prevented  very  largely.  Colitis 
occurs  with  the  pneumococcus  infection,  and  this  colitis  is 
undoubtedly  the  cause  of  the  development  of  tympanites;  the 
colitis  plus  the  toxemia  invites  an  intestinal  paresis.  Hence 
to  prevent  this  colitis  which  gives  rise  to  the  tympany,  it  is 
well  to  observe  carefully  the  diet,  regulating  judiciously  the 
amount  and  kind  of  food  taken,  and  washing  out  the  bowels 
with  normal  salt  solution." 

BRONCHOPNEUMONIA 

Under   two  years  of  age,  lobar  pneumonia  is  seldom   ever 
seen.    From  this  up  to  seven,  either  type  may  be  found.    After 

6    Journal  of  American  Medical  Association,  October  30,  1909,  1453. 


BRONCHOPNEUMONIA  243 

that  age,  lobar  pneumonia  is  the  prevailing  form.  In  many 
ways,  the  treatment  of  bronchopneumonia  is  conducted  on  the 
same  principles  as  that  for  the  lobar  type.  The  first  two 
indications,  i.  <?.,  increase  aeration  of  the  blood  and  sustain  the 
heart  and  circulation,  are  the  most  important.  Bronchopneu- 
monia is  nothingf  more  nor  less  than  an  extension  downward  of 
the  inflammation  of  a  bronchitis.  It  is  a  capillary  bronchitis  or 
lobular  pneumonia.  In  order  to  accomplish  the  first  result — the 
proper  aeration  of  the  blood — it  is  very  necessary  to  increase 
the  facility  and  the  amount  of  expectoration,  so  that  the  lungs 
may  be  free  for  proper  respiration.  The  child  may  be  placed 
in  a  bath  at  100°  and,  while  sitting,  receive  to  the  chest  and 
shoulders  cold  affusions  at  75° — 90°,  depending  upon  the  age 
and  vitality:  With  infants,  the  wet  sheet  pack  is  perhaps  the 
most  efficient  means.  The  pack  maybe  wrung  from  tepid,  cool 
or  cold  water  and  spread  out  on  a  blanket.  The  child  is  then 
placed  on  the  wet  sheet  which  is  wrapped  snugly  about  the 
body,  the  blanket  being  folded  over  all.  The  child  should 
remain  in  the  pack  to  the  sweating  stage.  At  first,  there  is 
gasping  respiration  and  the  child  cries.  This  aids  in  the 
expulsion  of  mucus.  As  the  pack  heats  up,  the  respiration 
becomes  deeper,  easier  and  the  expectoration  much  less  diffi- 
cult. Fever  may  drop  one  or  two  degrees  and  the  child  pass 
into  a  quiet  sleep.  If  this  occurs,  the  child  should  be  kept 
warm,  being  left  in  the  pack  until  it  awakes.  It  may  then  be 
taken  out  with  a  wet  hand  rub,  or  this  may  be  done  sooner  if 
the  child  does  not  sleep.  The  moist  chest  pack  and  heating 
compress  to  the  chest  are  also  efficient  means  of  sustaining  the 
heart  and  increasing  the  depth  of  respiration.  If  there  is  much 
cyanosis,  especially  if  accompanied  by  chilliness,  it  is  best 
to  place  the  child  in  a  full  warm  bath;  or,  if  the  pack  is 
used,  it  may  be  wrung  from  warm  water  or  hot  water.  In 
case  of  the  bath,  after  the  skin  has  become  well  warmed,  the 
child  may  receive  an  affusion  to  the  chest  or  to  the  entire  body 
just  as  it  is  taken  from  the  bath.  In  case  of  the  pack,  after  the 
child  is  well  warmed,  it  may  be  taken  out  with  a  wet -hand  rub. 
Infants  do  not  react  well  to  either  extreme  heat  or  cold.  For- 
tunately, however,  they  respond  to  milder  temperatures  in  as 
decided  a  manner  as  adults  do  to  greater  extremes. 


244  TREATMENT  OF  INFLAMMATIONS 

PLEURISY 

There  are  several  forms  of  pleurisy.  Only  the  treatment  of 
the  dry  and  serous  forms  will  be  considered,  since  empyema  of 
the  pleura  is  a  surgical  disease.  In  the  pleurisy  usually  accom- 
panying- pneumonia,  the  inflammation  is  largely  on  the  side  of  the 
visceral  layer.  In  ordinary  pleurisy,  however,  the  inflammation 
involves  chiefly  the  parietal  layer  of  the  pleura.  The  blood 
supply  of  the  two  layers  is  quite  different.  That  of  the  visceral 
layer  is  of  course  from  the  same  blood-vessels  as  the  lung:  itself, 
while  the  parietal  layer  is  supplied  by  the  blood-vessels  from 
the  intercostal  arteries  and  with  nerves  from  the  anterior  divis- 
ions of  the  intercostals.  It  has  been  shown  that  the  severe, 
acute  pain  in  both  peritonitis  and  pleurisy  originate  in  the 
parietal  layer  of  these  membranes.  With  these  facts  in  mind, 
it  will  be  seen  that  the  circulation  and  consequently  the  conges- 
tion of  the  visceral  layer  will  be  most  readily  influenced 
reflexly;  while  with  the  parietal  layer,  the  circulation  and 
congestion  are  influenced  to  a  greater  extent  by  hydrostatic 
means,  since  the  blood-vessels  are  connected  directly  with  those 
of  the  superficial  structures. 

For  these  reasons,  while  cold  decreases  reflexly  the  conges- 
tion in  the  lungs,  by  local  retrostasis  it  increases  the  congestion 
of  pleurisy.  In  acute  pleurisy,  cold  applications  greatly 
increase  the  pain  and,  if  used  persistently,  may  s6  prolong  the 
inflammation  that  weeks  or  months  are  required  for  its  entire 
relief. 

On  the  first  indications  of  pleurisy,  the  patient  should  be 
given  a  hot  foot  bath  for  the  purpose  of  warming  the  feet  and 
providing  for  thorough  reaction  to  any  other  treatment  that 
may  be  given.  This  also  aids  sweating  which  helps  to  relieve 
internal  congestion.  That  which  is  of  the  most  importance  is 
the  use  of  very  hot  fomentations  applied  over  the  affected  area. 
These  should  be  made  of  thick,  heavy  flannel,  wrung  from  boil- 
ing water  and  wrapped  in  one  thickness  of  dry  flannel.  No 
cold  should  be  applied  between  fomentations.  From  three  to 
five  may  be  necessary  in  order  to  completely  relieve  the  pain. 

If  one  side  only  is  affected,  these  fomentations  should 
be  applied  from  spine  to  sternum  and  not  simply  to  the 


PLEURISY  245 

chest  anteriorly  (.Plate  XII.) .  Given  in  this  manner,  the  hot 
application  dilates  the  posterior,  lateral  and  anterior  cutaneous 
branches  of  the  intercostal  arteries,  thus  withdrawing  the 
blood  from  the  congested  and  inflamed  pleura.  The  fomenta- 
tions to  the  chest  should  be  followed  by  a  heating  chest  pack. 
The  partial  pack,  so  arranged  that  the  moist  gauze  or  linen 
covers  only  the  affected  area,  is  better  than  the  full  pack.  In 
the  case  of  thin  persons  or  those  of  low  vitality,  it  is  best  to 
use  the  dry  chest  pack.  In  case  the  moist  chest  pack  is  used, 
it  may  be  necessary  to  apply  a  hot  water  bottle  over  the  area 
outside  of  the  pack  in  order  to  warm  it  more  promptly.  In  case 
of  diaphragmatic  pleurisy  the  fomentations  should  be  applied 
so  as  to  cover  the  area  of  insertion  of  the  diaphragm.  The 
upper  edge  may  reach  to  the  nipples  and  the  lower  edge  to 
the  navel.  They  should  be  large  enough  to  reach  to  the  poster- 
ior axillary  lines  on  each  side.  The  heating  compress  to  follow 
may  be  applied  by  means  of  a  moist  abdominal  bandage 
covering  the  same  region. 

After  two  or  three  treatments  in  which  fomentations  alone 
are  used,  with  possibly  a  cold  compress  after  the  last  one  of  each 
series,  the  revulsive  compress  should  be  used,  the  cold  com- 
press being  allowed  to  remain  until  thoroughly  warm  before 
the  second  fomentation  is  applied.  Later,  alternate  hot  and 
cold  by  means  of  fomentations  and  a  cake  of  ice  may  be  used; 
and  when  the  patient  is  convalescing,  the  alternate  hot  and 
cold  spray  douche  to  the  back,  front  and  sides  of  the  chest  gives 
excellent  results.  Percussion  or  force  should  not  be  used  in 
this  treatment  since  the  vibration  occasioned  by  it  tends  to 
increase  the  effusion.  Neither  should  any  massage  or  percus- 
sion be  given  to  the  chest  in  concluding  a  treatment.  Even  the 
vibration  of  a  vehicle,  such  as  a  street  car,  may  cause  the 
return  of  a  pleurisy  which  has  nearly  recovered,  and  the 
temperature  rise  two  degrees  or  more  in  a  single  hour. 

If  this  treatment  is  used  from  the  beginning,  that  is,  fomen- 
tations and  later  the  revulsive  compress  and  hot  and  cold, 
tapping  for  excessive  effusion  will  be  less  frequently  neces- 
sary. The  ice  bag  to  the  chest  should  not  be  used  in  any  stage 
of  pleurisy.  The  alternate  hot  and  cold  douche  to  the  feet,  or 


g46  TREATMENT  OF  INFLAMMATIONS 

the  alternate  hot  and  cold  foot  bath  should  replace  the  hot  foot 
bath  while  the  patient  is  convalescing:.  This  helps  to  steady 
the  circulation  and  render  exposure  to  cold  much  less  danger- 
ous. 

PERICARDITIS 

The  conditions  in  pericarditis,  while  very  similar 'to  those  in 
pleurisy,  must  be  treated  upon  somewhat  different  principles, 
because  of  differing  anatomical  relations.  While  the  lung  may, 
to  a  certain  extent,  be  immobilized  or  restricted  in  amplitude 
of  movement,  this  is  impossible  in  the  case  of  the  heart.  All 
that  can  be  hoped  in  this  line  is  to  decrease  the  frequency  of  its 
beat.  This  is  admirably  accomplished  by  the  use  of  the  ice 
bag  over  the  heart  and  especially  by  the  frequent  use  of  the 
cold  mitten  friction.  The  latter  is  perhaps  the  more  rational 
measure  since  by  its  stimulation  of  the  peripheral  vessels,  it 
relieves  the  heart  of  its  excessive  burden.  The  circulation  of 
the  parietal  layer  of  the  pericardium  is  more  or  less  connected 
with  the  surface  blood-vessels,  so  that  inflammation  may  be  re- 
duced in  the  same  manner  as  with  pleurisy.  Since  fomentations 
over  the  heart  increase  its  rate  and  decrease  its  force  through 
reflex  action,  it  is  not  possible  to  apply  them  as  we  do  in 
pleurisy.  The  best  results  may  be  obtainad  by  the  use  of  the 
ice  bag  applied  directly  over  the  heart,  while  a  very  large 
fomentation  is  so  arranged  as  to  cover  it  and  a  much  larger 
area  around  the  heart.  The  heat  produces  derivation,  while 
the  ice  bag  slows  the  heart  rate.  Three  of  these  fomentations 
may  be  given  in  succession  and  the  treatment  followed  by  the 
heating  compress;  or  the  ice  bag  may  be  left  on  between  treat- 
ments, being  removed  frequently  enough  to  preserve  the  reflex 
excitability  of  the  nerves.  During  the  course  of  pericarditis, 
the  cold  mitten  friction  should  be  used  one  to  three  times  a  day, 
-depending  upon  the  degree  of  the  heart  embarrassment. 

In  the  later  stages,  the  revulsive  compress  to  the  entire  front 
of  the  chest  should  be  used  to  promote  absorption.  Other 
treatments  that  are  of  advantage  are  the  hot  and  cold  foot  bath 
after  the  first  few  days,  also  hot  and  cold  to  the  spine  and  cold 
towel  rub.  It  is  not  necessary  to  do  paracentesis  unless,  by 
accumulation  of  fluid,  the  heart  is  seriously  interfered  with. 


RHEUMATIC  FEVER  247 

MYOCARDITIS 

This  is  very  frequently  met  with  in  diphtheria.  Since  the 
introduction  of  antitoxine,  it  is  of  course  less  frequent  and  less 
serious.  Myocardial  degeneration  and  consequent  cardiac 
asthenia  are  due  to  the  diphtheria  toxine.  It  may  not  become 
apparent  until  convalescence.  That  which  is  of  most  impor- 
tance is  absolute  rest.  The  ice  bag  to  the  precordia  should  be 
kept  in  place  a  great  deal  of  the  time.  This  slows  the  heart 
rate  and  increases  its  force  without  overstraining  the  cardiac 
muscle.  The  cold  mitten  friction  decreases  the  work  required 
of  the  heart  itself.  Both  the  cold  mitten  friction  and  the  ice 
bag  decrease  the  heart  rate  and  increase  its  force.  Digitalis 
and  strychnine  are  exceedingly  dangerous  in  this  condition  and 
should  never  be  used,  since  by  extreme  stimulation,  they 
compel  the  heart  to  overexert  itself.  Great  depression  results 
from  their  use. 

RHEUMATIC  FEVER 

Rheumatic  fever  is  an  acute,  infectious  disease,  primarily  an  in- 
flammation of  the  synovial  membranes  and  periarticular  tissues, 
with  a  special  tendency  to  involvement  of  other  serous  mem- 
branes, the  endocardium,  pericardium,  pleura  and  sometimes 
the  meninges.  A  more  severe  infection  may  be  complicated  by 
myocarditis.  In  ordinary  cases,  the  fever  is  moderate,  102.5° — 
103.5°,  but  it  may  be  very  high. 

Indications  of  first  importance  are  (l)  reduction  and  control 
of  the  inflammatory  process  in  the  joints;  (2)  prevention  and 
treatment  of  complications,  chiefly  endocarditis;  (3)  relief  of 
the  pain.  Formerly  synovitis  was  met  principally  by  hot 
applications,  heating  compresses,  counter-irritation  combined 
with  anodyne  mixtures  for  the  relief  of  pain.  The  local  appli- 
cations which  have  proven  helpful  are  fomentations,  the  dry 
pack  or  heating  pack  to  the  joint,  and  the  local  electric  light. 
They  should  be  continued  until  a  decided  hyperemia  of  the  skin 
is  produced.  After  rubbing  the  part  with  oil  of  wintergreen  a 
local  heating  pack  may  be  applied  and  allowed  to  remain  until 
the  next  treatment.  The  pain  in  the  joints  is  greatly  relieved 
by  these  measures.  The  internal  administration  of  the  natural 


248  TREATMENT  OF  INFAMMATIONS 

oil  of  wintergreen  in  20  minim  doses  every  two  to  four  hours 
also  adds  to  the  comfort  of  the  patient  and  seems  to  shorten  the 
course  of  the  inflammation.  We  have  never  seen  any  harmful 
results  from  its  use. 

Hot  applications  frequently  fail  to  produce  the  best  results. 
Where  continuous  cold  to  the  joints  has  been  tried,  it  has  been 
found  to  give  better  results  than  hot  applications.  The  joint 
should  be  well  covered  with  a  thick  flannel  cloth,  outside  of 
which  should  be  packed  cracked  ice  or  snow  (Plate  XIII.}  or 
the  joint  may  be  surrounded  with  ice  bags.  This  pack  should 
be  left  in  place  until  the  part  becomes  almost  numb,  care  being- 
taken  that  actual  freezing  does  not  occur.  At  the  same  time, 
the  warmth  of  the  body  should  be  sustained  by  hot  water 
bottles,  the  foot  bath,  or  fomentations  to  other  parts.  When 
the  pack  has  been  in  place  a  sufficient  length  of  time  to  do 
away  with  tenderness,  it  may  be  removed  and  the  skin  rubbed 
thoroughly  with  the  dry  hand  or  snow  until  it  is  red.  If  the 
inflammation  is  severe,  the  ice  pack  should  then  be  replaced. 
The  rubbing  must  be  repeated  at  intervals  to  promote  reaction 
and  prevent  freezing.  If  thought  necessary,  this  opportunity 
may  be  taken  to  mobilize  the  joint.  In  the  ordinary  case  the 
heating  compress  may  be  used  between  the  ice  packs,  the 
latter  being  repeated  from  two  to  four  times  a  day,  each  lasting 
for  thirty  minutes  to  one  hour.  Two  or  three  joints  may  be 
treated  in  this  manner  at  the  same  time.  When  these  extreme 
cold  applications  are  used,  the  inflammation  seems  to  run  a 
much  shorter  course.  Where  moderate  movement  of  the 
patient  is  not  objectionable,  the  use  of  alternate  extreme  hot 
and  cold  immersion  of  the  hands  and  wrists  or  feet  and  ankles 
is  one  of  the  best  measures  for  controlling  the  pain  and  inflam- 
mation in  these  joints.  This  is  especially  applicable  when  the 
inflammation  has  subsided  somewhat. 

•The  patients  general  vitality  should  be  sustained  by  cold 
mitten  frictions,  hot  and  cold  to  the  spine,  and  the  heart 
steadied  by  the  use  of  the  ice  bag  and  cold  mitten  friction. 
Fomentations  to  the  chest  may  be  used  every  four  or  five  hours, 
or  oftener  if  necessary,  in  order  to  renew  the  reflex  activity 
where  the  ice  bag  is  used  for  a  considerable  length  of  time. 


RHEUMATIC  FEVER  249 

Free  water-drinking  should  be  encouraged.     An  actual  sweat- 
ing treatment  is  beneficial  and  may  be  employed  daily  or  two 
or  three  times  a  week.     Both  of  these  measures  favor  elimin-' 
ation  of  toxines.     If  this  plan  of  treatment  is  thoroughly  carried 
out,  endocarditis  is  less  likely  to  occur. 

Endocarditis.  Should  the  valvular  endocardium  become 
involved,  it  is  necessary  to  keep  the  patient  at  perfect  rest, 
both  during  the  course  of  the  fever  and  for  a  considerable  time 
after.  The  ice  bag  to  the  heart  should  be  used  intermittently; 
that  is,  being  put  on  for  twenty-five  or  thirty  minutes  and  left 
off  for  the  same  length  of  time,  or  even  allowing  it  to  remain 
in  place  for  a  longer  time,  depending  upon  the  results  produced. 
Buxbaum7and  Laqueur 8  recommend  the  use  of  the  cold  coil 
to  the  precordia  two  or  three  times  daily  for  a  half  hour  to  an 
hour,  or  even  longer  at  a  time. 

Cold  mitten  frictions  should  be  given  from  one  to  three  times 
daily,  hot  foot  baths  being  used  as  frequently  as  necessary.  It 
is  needless  to  say  that  the  heart  should  be  examined  daily,  the 
findings  being  compared  with  the  clinical  manifestations. 
After  the  fever  has  subsided, .  the  patient  must  be  carefully 
guarded  from  all  exposure  to  cold  and  damp.  He  should 
return  to  an  active  condition  very  gradually,  rest  in  bed  being 
kept  up  until  the  pulse  rate  is  nearly  normal.  The  wheel  chair 
may  be  used  from  this  point,  but  before  further  advancement 
may  be  made,  the  pulse  rate  must  again  return  to  normal. 
The  patient  may  then  be  allowed  to  lounge  about,  being 
dressed  and  around  the  room  part  of  the  time.  Walking  should 
not  be  allowed  if  the  pulse  rises  above  ninety.  During,  all  this 
time,  such  tonic  measures  as  hot  and  cold  to  the  spine,  the  cold 
mitten  friction  and  cold  towel  rub  should  be  used.  After  the 
subsidence  of  the  fever,  gentle  massage  may  be  permitted. 
The  resistant  movements  of  the  Schott  method,  and  the  effer- 
vescent bath  should  not  be  given  until  well  into  convalescence ; 
that  is,  after  the  fever  has  been  normal  for  a  month  or  two. 
From  this  on,  the  treatment  is  essentially  that  of  chronic 
endocarditis  (q.v.}. 

7  Lehrbuch  der  Hydrotherapie,   1903,  p.  234. 

8  Die  Praxis  der  Hydrotherapie,  1910,  p.  143. 


250  TREATMENT  OF  INFLAMMATIONS 

INFECTIOUS  ARTHRITIDES 

Not  only  in  rheumatic  fever  but  also  in  a  number  of  other 
infections,  arthritis  is  a  prominent  and  often  very  troublesome 
occurrence.  Some  of  these,  especially  in  the  chronic  stage 
respond  well  to  the  use  of  vaccines,  but  we  have  obtained  more 
uniform  and  satisfactory  results  from  the  use  of  scientific 
hydrotherapy.  In  these  arthritides  we  include  gonorrheal 
rheumatism,  syphilitic  arthritis,  and  the  secondary  non-suppti- 
rative  arthritis  of  scarlet  fever,  tonsillitis  and  other  infectious 
fevers.  The  principles  and  methods  of  treatment  are  very 
definite.  For  clinical  purposes  the  cases  may  be  divided  into 
acute  and  chronic. 

The  Acute  Stage.  Each  inflamed  joint  should  be  packed  in 
ice  for  thirty  minutes  to  one  hour  two  or  three  times  a  day. 
The  more  acute  the  inflammation  the  greater  should  be  the 
total  duration  of  the  cold.  At  the  close  of  each  of  these  appli- 
cations some  treatment  should  be  given  to  promote  reaction. 
This  may  be  by  rubbing  with  snow  or  by  two  or  three  changes 
of  an  alternate  hot  and  cold  immersion,  pour,  or  spray  douche. 
As  the  inflammation  progresses  toward  the  chronic  stage,  more 
heat  and  less  cold  should  be  used. 

The  Chronic  Stage.  When  an  infectious  arthritis  has  existed 
some  weeks  or  months  the  treatment  should  differ  radically 
from  that  which  is  given  during  the  first  few  days  or  week  or 
two  of  the  inflammation.  For  chronic  arthritis  apply  to  the 
joint  some  form  of  hot  application.  This  may  be  the  fomen- 
tation (Plate  X/y.),  the  local  electric  light,  or  superheated  air. 
After  ten  to  thirty  minutes  of  such  applications  treat  the  part 
by  a  vigorous  alternate  hot  and  cold  immersion  or  alternate 
spray  douche,  using  from  three  to  six  or  more  changes.  The 
spray  douche  is  better  than  the  immersion.  The  hot  water 
should  be  as  hot  as  can  be  borne  and  the  cold  as  cold  as  it  can 
be  obtained,  which,  for  the  best  results,  should  not  be  above 
60  F.  If  there  is  pain  in  the  joint  or  if  it  should  seem  desir- 
able for  other  reasons,  the  heating  joint  compress  may  be 
applied  after  each  treatment  and  kept  on  until  the  next  treat- 
ment. 


PLATE  XIII.     The  application  of  the  ice  pack  to  the  knee  in  rheumatic  fever 
and  acute  arthritis. 


PLATE  XIV.    Method  of  applying  fomentations  to  the  knee  in  chronic  arthritis 


MENINGITIS  251 

These  methods  have  given  such  uniformly  satisfactory  results 
that  infectious  arthritis  has,  with  us,  ceased  to  be  a  perplexing 
problem. 

MENINGITIS 

In  acute  cerebro-spinal  meningitis,  there  is  a  purulent 
exudate  covering:  the  convex  dorsal  surfaces  of  the  brain 
between  the  dura  mater  and  the  leptomeninges  filling1  the 
meshes  of  the  arachnoid  and  extending-  downward  along-  the 
cord.  The  meninges  of  the  brain  are  intensely  congested. 
The  intracranial  pressure  is  increased.  Quincke's  lumbar 
puncture  should  be  used  for  diagnosis  and  treatment.  The 
most  important  treatment  is  the  use  of  Flexner 's  serum,  which 
has'  given  75  per  cent  of  recoveries  in  four  hundred  cases. 
The  most  commonly  employed  hydrotherapeutic  applications 
are  the  ice  cap  and  spinal  ice  bag  applied  continuously,  or  with 
but  little  interruption.  The  spinal  ice  bag  should  be  filled  with 
finely  pounded  ice  and  placed  along-  the  cervical  and  upper 
dorsal  spine.  Another  smaller  ice  bag  should  be  placed  cross- 
wise of  the  neck  at  the  base  of  the  brain.  The  ice  cap  or 
helmet  should  cover  as  large  an  area  as  possible  of  the  convex 
surface  and  sides  of  the  cranium.  These  applications,  though 
extensive  and  extreme,  do  not  usually  cause  chilling.  It  will 
be  found  helpful  to  apply  heat  to  the  extremities  at  intervals. 
The  hot  foot  bath,  hot  leg  pack,  or  large  fomentations  to  the 
limbs  and  abdomen,  may  be  used.  They  assist  the  action  of 
the  ice  bags  in  reducing-  cerebral  congestion.  The  ice  bags 
and  ice  cap  may  conveniently  be  replaced  by  rubber  coils  through 
which  ice  water  is  flowing. 

Rohrer  reports  a  number  of  cases  in  which  cold  affusions  to 
the  head  and  neck  were  of  great  service  in  relieving-  or  mitigat- 
ing the  severity  of  cerebral  symptoms  and  bringing  about  a 
successful  termination.  He  also  advises  the  cold  affusion  for 
the  relief  of  cerebral  symptoms,  whether  delirium  or  coma, 
accompanying-  infectious  diseases  such  as  pneumonia,  acute 
meningitis  and  in  sunstroke,  neoplasms  and  tubercular  menin- 
gitis. When  made  very  cold  and  much  prolonged,  they  are 
decidedly  antipyretic. 

In  chronic  and  tubercular  meningitis  the  opisthotonos,  and 


252  TREA  TMENT  OF  IN  FA  MM  A  TIONS 

muscular  ridigity  are  best  met  by  the  use  of  the  full  warm  bath 
given  at  a  temperature  of  98° — 102°  F.  These  may  be  con- 
tinued from  ten  or  fifteen  minutes  to  an  hour,  according-  to  the 
needs  of  the  case.  The  restlessness,  delirium  and  headache 
are  often  entirely  relieved.  The  rigidity  of  the  spine  and 
abdominal  muscles  is  favorably  influenced.  We  have  seen 
coma  give  way  to  a  fairly  clear  sensorium  following  the 
bath.  Where  the  temperature  of  the  patient  is  above  102°,  the 
ice  bag  should  be  kept  at  the  base  of  the  brain  and  a  cold 
compress  to  the  head  during  the  bath.  This  is  especially 
necessary  in  the  epidemic  form  of  cerebro-spinal  meningitis. 
In  tuberculous  meningitis  it  may  not  be  needed.  Aufrecht, 
Waroschilsky,  Wollisch,  Netter  and  others  report  favorable 
results  from  the  full  warm  bath.  Rogansky  reports  among 
fifty-one  cases  (not  tubercular)  in  women  where  the  warm  bath 
was  used,  a  mortality  of  33  per  cent;  and  among  fifty  cases  where 
the  bath  was  not  used,  a  mortality  of  80  per  cent.  The  warm 
bath  acts  as  a  relaxing  and  sedative  agent.  It  also  aids  in 
depleting  the  cerebral  and  spinal  circulation  and  serves  as  a 
tonic  to  the  circulatory  system.  Excitant  and  stimulating 
measures  should  be  avoided. 

BILIARY  INFLAMMATIONS 
Cholecystitis,  Catarrhal  Juandice,  Subacute  Pancreatitis 

Inflammatory  states  in  these  ducts  and  organs  are  quite  likely 
to  be  followed  by  conditions  that  require  operative  interference; 
but  if  taken  early,  the  milder  inflammations  subside  under 
proper  treatment.  In  cases  of  subacute  pancreatitis  and 
catarrhal  inflammation  of  the  gall  bladder  and  ducts,  we  have 
found  the  following  method  successful:  Once  or  twice  daily 
there  should  be  given  a  treatment  consisting  of  a  hot  foot  bath 
with  fomentations  to  the  abdomen  and  concluded  by  the  cold 
mitten  friction.  The  hot  foot  bath  and  fomentations  produce 
effectual  derivation,  while  the  latter  application  relieves  the 
pain  and  relaxes  the  musculature  of  the  ducts  and  the  gall 
bladder.  The  cold  mitten  friction  is  given  for  tonic  purposes, 
to  increase  leucocytosis  and  combat  infection.  Fomentations 
and  hot  and  cold  to  the  spine  are  used  for  sedative  and  tonic 


APPENDICITIS  253 

purposes.  As  the  patient  improves,  the  revulsive  compress  to 
the  abdomen  may  be  used,  also  the  graduated  shower,  hot  and 
cold  spray  and  the  alternate  douche.  Once  a  week  a  short 
electric  light  bath  should  be  given. 

From  the  beginning  of  the  inflammation,  the  patient  should 
wear  some  form  of  heating  compress  to  the  abdomen.  This 
is  most  conveniently  applied  by  means  of  the  moist  abdominal 
girdle.  The  ice  bag  or  other  continuous  cold  applications  to 
the  abdomen  should  not  be  used  in  these  conditions.  In  case 
of  empyema  of  the  gall  bladder,  should  the  patient  refuse 
operation  or  a  brief  delay  seem  advisable,  the  same  plan  should 
be  followed.  It  is  inadvisable  to  use  the  ice  bag  in  such  a 
condition,  since  it  tends  to  cause  firm  contraction  of  the  mus- 
cular coat  and  might  occasion  rupture  of  the  gall  bladder.  In 
fact,  it  is  a  principle  which  should  be  quite  generally  followed 
that  inflammations  of  the  hollow  viscera  are  best  treated  by  hot 
applications.  This  is  also  true  of  the  urinary  bladder.  The 
spasm  of  the  muscles  occasioned  by  the  inflammation  is  relaxed 
and  the  congestion  decreased. 

Catarrhal  jaundice  in  about  60  per  cent  of  cases  is  now 
considered  to  be  due  to  the  induration  in  the  head  of  the  pan- 
creas occasioned  by  a  subacute  inflammation.  Outside  of  the 
dietetic  treatment  of  this  condition  and  the  special  necessity  for 
free  bowel  movement,  it  should  be  treated  on  the  same  general 
principles  as  those  outlined  above. 

APPENDICITIS 

As  we  have  previously  remarked,  this  is  a  surgical  disease 
and  should  be  surgically  treated  in  practically  all  cases.  Hydro- 
therapy  produces  such  marvelous  results  in  the  relief  of  pain 
and,  in  many  cases,  safe  conduct  to  the  interval  that  it  might 
almost  seem  to  be  a  specific.  This  temporary  relief,  however, 
can  not  be  depended  upon  for  permanent  cure.  Should  it  seem 
advisable  to  delay  operation  to  the  interval  or,  in  case  the 
patient  refuses  operation,  hydrotherapy  offers  the  best  chances 
for  immediate  recovery. 

The  patient  should  be  given  a  hot  hip  and  leg  pack  with  an 
ice  bag  inserted  under  the  edge  of  the  blanket  just  over  the 


254  TREATMENT  OF  INFLAMMATIONS 

appendix.  By  means  of  the  combined  effect  of  the  hot,  in 
drawing:  the  blood  from  the  inflamed  part,  and  the  ice  bag-,  in 
causing  contraction  of  the  vessels  reflexly,  the  most  effectual 
derivation  is  secured.  The  pain  is  almost  instantly  relieved 
in  those  cases  in  which  the  inflammation  has  not  produced 
rupture  of  the  appendix.  After  twenty  or  thirty  minutes  in 
the  pack,  it  should  be  removed  and  a  vigorous  cold  mitten 
friction  be  given  to  all  parts  included  by  it,  except  the  abdo- 
men. This  serves  to  fix  the  blood  in  the  skin  and  so  make 
derivation  more  permanent.  Following  this  treatment,  the 
heating  compress  may  be  applied  to  the  lower  abdomen  or  the 
ice  bag  may  be  applied  over  the  appendix  almost  continuously. 
The  hip  and  leg  pack  with  ice  bag  should  be  repeated  as  often 
as  necessary  to  relieve  the  pain  and  make  the  patient  comfort- 
able. It  is  perhaps  needless  to  say  that  the  treatment  should 
be  preceded  by  a  thorough  enema.  Cathartics  should  be 
avoided.  A  very  large  fomentation  with  an  ice  bag  under  the 
center  over  the  appendix  may  be  substituted  for  the  pack. 
After  the  temperature  has  become  normal  and  the  acute  tender- 
ness has  subsided,  the  patient  should  be  given  general  tonic 
treatments,  always  avoiding  extreme  measures  to  the  abdomen 
or  about  the  appendix,  since  excitation  of  peristalsis  may  cause 
return  of  the  inflammation  or  rupture  of  the  appendix.  In 
chronic  appendicitis  the  fomentation  to  the  abdomen  is  best 
calculated  to  relieve  the  pain  and  tenderness.  Where  possible, 
these  cases  should  be  operated  in  the  interval. 

PELVIC  INFLAMMATIONS 

Acute   Endometritis    from   Puerperal   Sepsis,   Salpingitis, 
Ovaritis,  Pelvic  Cellulitis  and  Peritonitis 

It  is  necessary  to  differentiate  between  these  conditions, 
although  hydriatic  treatment  is  carried  out  along  much  the 
same  line  in  all.  In  the  case  of  retained  secundines  following 
labor  or  abortion,  it  is  imperative  to  perform  currettage  as 
early  as  possible.  In  the  case  of  simple  salpingitis,  operation 
should  not  be  done  at  all.  Should  the  inflammation  go  on  to 
the  formation  of  a  pyosalpinx,  operation  should  be  delayed 


PELVIC  INFLAMMATIONS  255 

until  the  temperature  is  normal  and  the  acute  inflammation  has 
subsided.  In  pelvic  cellulitis  operation  is  unnecessary  and 
dangerous.  Should  abscess  formation  occur,  either  in  the 
cellular  tissue  or  in  the  peritoneal  cavity,  drainage  should  be 
provided. 

With  these  different  conditions  in  mind  and  the  possible  out- 
come of  each,  the  inflammation  should  be  treated  in  the  same 
manner  as  that  outlined  for  appendicitis.  The  patient  may  be 
given  the  hot  leg  pack  or  hip  and  leg  pack,  with  the  ice  bag 
applied  to  the  groin,  suprapubic  region  or  other  part  nearest 
the  inflamed  organ.  This  should  be  continued  twenty  to  thirty 
minutes  and  concluded  with  the  cold  mitten  friction.  The 
heating  compress  may  be  applied  or,  if  it  seems  wise,  in  some 
cases  the  ice  bag  may  be  left  in  placs.  In  other  cases,  fomen- 
tations to  the  lower  abdomen  may  be  given  every  two  hours. 
The  hip  and  leg  pack  with  the  ice  bag,  followed  by  the  cold 
mitten  friction,  should  be  repeated  two  or  three  times  daily 
according  to 'the  necessities  of  the  case.  It  is  well,  in  nearly 
all  of  these  inflammations,  to  precede  the  pack  by  very  hot 
vaginal  irrigation.  As  the  acuteness  of  the  inflammation 
subsides,  the  revulsive  compress  and  other  alternate  hot  and 
cold  applications  may  be  used.  Perhaps  the  most  effectual 
means  of  treating  chronic  pelvic  inflammations  is  found  in  the 
sitz  bath.  When  it  is  considered  safe  to  allow  the  patient  to 
begin  to  walk,  the  hot  sitz  or  revulsive  sitz  may  be  used.  The 
temperature  of  the  bath  should  be  gradually  lowered  until  the 
patient  is  taking  a  hot  sitz  followed  by  a  brief  application  of 
cold  or  very  cold  water.  The  hot  half  bath  is  an  effectual  means 
of  applying  the  principles  of  the  sitz  bath.  In  some  cases,  it  is 
to  be  preferred.  The  body  is  less  cramped  and  both  the  limbs 
and  hips  are  entirely  immersed  in  the  water.  At  the  conclu- 
sion, the  patient  should  receive  a  cold  pail  pour  to  the  hips.  It 
is  not  necessary  to  use  the  extreme  or  prolonged  cold  sitz  in 
the  conditions  mentioned  above.  In  place  of  this,  the  patient 
should  be  given  alternate  hot  and  cold  percussion  douches  to 
the  sacrum,  feet,  and  legs.  Other  tonic  measures  should  form 
part  of  the  course  of  treatment.  The  cold  rubbing  sitz  is  bene- 
ficial in  delayed  resolution.  Hot  vaginal  irrigation  or  alternate 


256  TREATMENT  OF  INFLAMMATIONS 

hot  and  cold  irrigation  should  be  used  until   resolution  is  com- 
plete. 

PHLEBITIS 

During:  the  early  stages  of  phlebitis,  the  cold  compress  or  ice 
bag-  should  be  used  over  the  affected  vein.  At  the  same  time, 
the  limb  must  be  elevated  and  kept  warm.  All  massage  move- 
ments are  strictly  contra-indicated  in  this  condition.  After  the 
first  day  or  so,  fomentations  should  be  used  frequently,  the  ice 
bag:  or  cold  compress  being  left  in  place  between  fomentations. 
While  the  patient  is  recovering,  that  is,  after  the  temperature 
becomes  normal  and  all  signs  of  acute  inflammation  have  sub- 
sided, the  revulsive  compress  may  be  used.  The  edema  should 
be  treated  by  elevation  and  such  alternate  hot  and  cold  meas- 
ures as  the  revulsive  compress,  hot  and  cold  foot  or  leg  bath 
and  the  alternate  pour.  When  there  is  no  longer  danger  from 
embolism,  massage  may  be  used,  avoiding,  however,  the  vein 
itself.  Later  on,  when  there  remains  only  the  stasis  and 
edema,  the  most  vigorous  hot  and  cold  measures  such  as  the 
alternate  douche,  are  beneficial. 

MUCOUS   COLITIS 

The  first  object  to  be  accomplished  in  the  treatment  of 
mucous  colitis  is  the  removal  of  the  mucous  cast  covering  the 
mucous  membrane.  The  thorough  removal  of  this  coating  will 
be  accompanied  by  more  or  less  pain,  since  it  leaves  a  raw, 
unprotected  surface.  That  which  most  effectually  removes  the 
coating  is  some  form  of  treatment  which  will  produce  a  vigor- 
ous exosmosis.  This  may  be  accomplished  by  the  hypertonic 
saline  enema,  or  the  honey  enema.  In  preparing  the  saline 
enema,  about  double  the  amount  of 'salt  should  be  added  as  in 
preparing  a  physiologic  salt  solution,  or  to  each  pint  of  saline 
solution  there  may  be  added  a  quarter  of  a  teaspoonful  of 
Epsom  salts.  This  tends  to  draw  water  from  the  tissues 
because  of  the  concentration  of  the  solution.  Before  using  the 
salt  solution,  the  bowel  should  be  thoroughly  cleansed,  if  nec- 
essary, by  both  low  and  high  enemata;  after  which  the  salt 
solution  is  introduced  by  means  of  the  high  bowel  catheter,  or 
by  the  ordinary  enema  given  in  the  knee -chest  position.  A 


CYSTITIS  257 

pint  or  even  a  quart  of  the  solution  may  be  used  at  one  time. 
It  should  be  retained  as  long-  as  possible,  twenty  to  thirty 
minutes  is  sufficient.  Owing-  to  the  cathartic  action  it  can  not 
ba  retained  long".  It  usually  brings  away  with  it  considerable 
of  the  tenacious  mucus,  often  in  cast  form.  The  pain  and 
tenderness  occasioned  by  the  enema  may  be  relieved  by  fomen- 
tations to  the  abdomen,  and  the  weakness  induced  by  such 
drastic  measures  somewhat  relieved  by  the  cold  mitten  friction. 

The  enema  should  be  repeated  about  three  times  a  week  and 
continued  until  there  is  little  or  no  mucus  brought  away  with 
the  passagfe  of  the  salt  solution. 

The  molasses  or  molasses  and  soap  suds  enema  may  be  sub- 
stituted for  the  concentrate  salt  solution.  If  given,  it  is  nec- 
essary to  warm  it  slig-htly  so  that  it  may  pass  readily  through 
the  colon  tube.  From  three  to  six  weeks  of  such  treatment 
may  be  necessary  in  order  to  thoroughly  rid  the  bowel  of  the 
mucus  coating-.  After  this,  the  enemata  should  be  entirely 
discontinued,  the  patient  being  given  general  tonic  treatment, 
including-  fomentations  to  the  abdomen.  The  following  plan 
will  be  found  helpful:  In  the  morning-  a  treatment  consisting  of 
a  hot  foot  bath,  fomentations  to  the  abdomen,  and  a  cold  mitten 
friction.  The  revulsive  compress  to  the  abdomen  may  also  be 
used.  In  the  afternoon  hot  and  cold  to  the  spine,  followed  by 
a  cold  towel  rub  or  g-eneral  massage,  avoiding  the  abdomen. 
The  patient  rapidly  regains  the  weight  and  strength  lost  dur- 
ing- the  first  part  of  the  treatment  and  after  a  few  weeks  there 
is  usually  no  more  mucus  discharged  from  the  bowel.  It  of 
course  goes  without  saying-  that  the  underlying-  neurasthenic 
condition  and  derangements  of  digestion  should  receive  their 
share  of  attention  by  rest,  proper  diet,  etc. 

CYSTITIS 

In  the  acute  stage  only  hot  treatment  is  permissible.  This 
may  be  given  by  means  of  a  hot  hip  pack,  fomentations  to  the 
lower  abdomen  and  pelvis,  or  the  hot  sitz  or  revulsive  sitz. 
Neither  the  ice  bag-  nor  cold  compress  should  be  used.  Both 
of  these  measures  cause  contraction  of  the  bladder  muscles  and 
so  increase  the  pain  arising  from  the  inflamed  mucous  mem- 

17 


258 


TREATMENT  OF  INFLAMMATIONS 


brane.  The  hot  applications- tend  to  relax  the  musculature  and 
draw  blood  from  the  organ  to  the  surface.  The  patient  should 
drink  freely  of  water  in  order  to  dilute  the  urine,  thus  lessen- 
ing" its  irritating  qualities.  Regulation  of  the  diet  is  fully  as 
important  as  these  measures. 

In  the  chronic  stage  more  cold  treatment  may  be  us'ed,  such 
as  the  revulsive  sitz,  graduated  sitz,  hot  and  cold  perineal 
spray,  hot  and  cold  rectal  irrigation,  and  the  alternate  spray 
douche  to  the  pelvis.  These  alternate  applications  may,  at 
first,  occasion  some  vesical  spasm,  but  if  persisted  in,  help  to 
relieve  the  stagnant  circulation. 
The  hot  saline  enema  and  continu- 
ous hot  rectal  irrigation  also  pro- 
duce good  results.  Bladder  irriga- 
tion with  hot  physiologic  salt  solu- 
tion or  some  mild  antiseptic  as 
boric  acid  or  potassium  perman- 
ganate should  be  done  once  daily, 
rarely  oftener.  In  long  standing 
chronic  cases  alternate  hot  and 
cold  rectal  irrigation  gives  excel- 
lent results.  This  plan  of  treat- 
ment is  especially  beneficial  in 
those  cases  in  which  the  capacity  Fig- 53-  The  Perineal  douche, 
of  the  organ  is  very  much  reduced  and  the  walls  have  become 
greatly  thickened  and  indurated. 

SPECIFIC  URETHRITIS,  VAGINITIS,  OR   PROSTATITIS 

In  the  acute  stage,  in  addition  to  the  local  medication,  the  ice 
bag  should  be  used  almost  continuously.  The  Leiter  coil  is  an 
excellent  means  of  continuous  cooling.  Some  form  of  internal 
.cooler  may  be  used.  The  hollow  prostatic  cooler  which  is 
applied  to  the  prostate  through  the  rectum  is  useful  in  decreas- 
ing acute  inflammations  of  that  organ.  Desnos  recommends 
very  hot  (120°  F.)  rectal  irrigation  in  the  acute  stages,  forbid- 
ding it  in  the  chronic  stage.  We  would  reverse  this  rule, 
using  cold  rectal  irrigation  in  the  acute  stage  and  vigorous  hot 
and  cold  in  the  chronic  stage.  As  these  conditions  progress  to- 


.  SPECIFIC  URETHRITIS  259 

ward  the  chronic  stage,  short  hot  applications  should  be  used,  al- 
ternating" with  the  cold,  and  after  the  acute  inflammation  has 
subsided,  the  most  vigorous  hot  and  cold  measures  are  necessary. 
That  which  is  the  most  serviceable  is  the  alternate  hot  and 
cold  perineal  spray.  (Fig.  53.}  Chronic  cases  which  have 
resisted  all  sorts  of  medication  very  readily  respond  to  this 
measure.  It  greatly  increases  the  circulation  and  stimulates 
local  leucocytosis,  both  of  which  are  necessary  in  order  to  com- 
bat the  infection  which  frequently  becomes  cryptic  in  this  stage 
and  so  is  beyond  the  reach  of  topical  medication.  The  grad- 
uated sitz  or  even  the  cold  sitz  may  also  be  used.  This  should 
be  begun  at  a  temperature  of  98° — 105°,  and  after  one  or  two 
minutes,  the  temperature  gradually  lowered  to  85°,  or  after 
several  applications,  to  as  low  as  75°.  The  bath  should  last 
from  four  to  six  or  eight  minutes,  and  be  followed  by  the  alter- 
nate hot  and  cold  perineal  spray.  In  chronic  prostatitis  alter- 
nate hot  and  cold  rectal  irrigation  produces  astonishingly  good 
results. 


CHAPTER  XX 
STIMULANTS  AND  TONICS 

THERE  is  a  decided  difference  in  the  physiologic  effects  of  a 
stimulant  and  a  tonic.  The  idea  that  stimulants  are  neces- 
sary for  tonic  purposes  has  lead  to  great  confusion  in  the 
proper  understanding  of  these  terms.  While  tonics  have  a 
wide  range  of  applicability,  the  necessity  for  stimulants  is 
much  more  limited.  We  quote  the  following  from  Sir 
William  Broadbent  as  giving  the  best  idea  of  the  effects  pro- 
duced by  stimulants:  "A  falsehood  which  dies  hard  is  the  idea 
that  stimulants  of  whatever  kind  actually  give  strength  and 
are  necessary  for  the  maintenance  of  health  and  vigor.  Such 
is  not  the  case  and  the  well-worn  comparison  that  they  are  the 
whip  and  spur,  and  not  the  corn  and  grass,  is  strictly  accurate. 
Anything  accomplished  under  the  influence  of  stimulants  is 
done  at  the  expense  of  blood  and  tissue  and,  if  frequently  re- 
peated, at  the  expense  of  the  constitution." 

On  the  other  hand,  a  tonic  tends  to  restore  the  body  to  such 
a  condition  that  it  is  better  able  to  perform  its  usual  functions. 
It  not  only  "stimulates"  and  hastens  the  normal  expenditure 
of  energy,  but  it  also  increases  the  vital  capacity  of  the  body 
for  work.  This  it  does  by  its  action  in  augmenting  the  pro- 
cesses of  anabolism.  It  will  be  seen  from  this  that  the  whip 
can  not  be  a  tonic,  since  it  in  no  way  tends  to  restore  an  organ 
to  its  normal  condition,  nor  does  it  so  shape  circumstances 
that  the  tissues  of  the  organ  are  built  up.  For  this  reason 
strychnine  should  be  considered  a  stimulant,  and  a  stimulant 
only.  All  tonic  measures  are  physiologic  in  their  nature, 
while  stimulants  may  or  may  not  be  natural  means.  Medicinal 
stimulants  produce  an  unnatural  condition  which  in  no  way 

(260) 


HYDRIATIC  TONICS  261 

tends  to  restore  to  the  normal.  On  the  contrary,  while  physio- 
logic stimulants  may  excite  an  unusual  expenditure  of  energy, 
greater  in  this  direction  than  in  the  building  up  of  the  vitality, 
yet  they  do  not  have  the  bad  after  effects  constantly  observed 
following  the  use  of  such  stimulants  as  strychnine. 

In  the  consideration  of  physiologic  means,  we  may  properly 
divide  measures  which  enhance  vital  activity  into  two  classes,* 
— those  which  are  largely  or  wholhT  excitant  and  stimulating, 
and  those  which  are  chiefly  tonic  in  their  effects. 

HYDRIATIC  MEASURES  CHIEFLY  TONIC 

Tonic  effects  are  derived  principally  from  cold  applications. 
The  reaction  to  vigorous  cold  measures  has  been  shown  to  in- 
crease muscular  capacity,  quicken  the  circulation,  enhance 
nerve  activity,  etc.  In  this  sense,  tonic  effects  may  be  consid- 
ered to  be  a  secondary  result  or  reaction  from  the  primary 
stimulation.  Tonic  effects  may  also  be  had  from  alternate  hot 
and  cold  applications,  never  from  hot  alone,  except  they  be 
very  short  or  where  the  heat  of  the  body  is  much  below  par. 

That  the  wide-spread  effects  of  tonic  applications  may  be 
fully  realized  by  the  reader,  we  give  below  a  tabulated  list  of 
such  effects.  These  have  been  discussed  in  detail  in  the  first 
part  of  this  work. 

Cold  applications  produce  the  following  tonic  effects: — 

1.  Quicken  the  circulation  of  the  blood  and  lymph. 

2.  Strengthen  the  heart  beat. 

3.  Raise  blood  pressure. 

4.  Increase  glandular  activity. 

5.  Enhance  nerve  activity. 

6.  Augment  assimilation. 

7.  Increase  depth  of  respiration. 

8.  Increase  amount  of  oxygen   absorbed  and  carbon  dioxide 
eliminated. 

9.  Leucomaines  are  more  perfectly  oxidized. 

10.  Increase  oxidation  and  metabolism  in  general. 

11.  Stimulate  heat  production. 

12.  Equalize  the  distribution  of  red  and  white  blood  cells,  in- 


262  STIMULANTS  AND  TONICS 

creasing:  their  number  in  the  peripheral  circulation  and  thereby 
preventing1  globular  stasis. 

13.  Increase  alkalinity  of  the  blood. 

14.  Augment   the    production    of   agglutinin  and  other  anti- 
bodies. 

15.  Stimulate  phag-ocytosis. 

•  16.  Increase  muscular  capacity. 
17.  Decrease  fatigiie. 

Tonic  measures,  to  a  greater  or  less  extent,  are  indicated  in 
all  forms  of  disease.  In  some  conditions  the  tonic  results 
derived  from  measures,  whose  principal  effects  are  other  than 
tonic,  are  sufficient  to  secure  recovery;  but  in  nearly  all  diseases 
some  special  tonic  treatment  is  needed,  and  in  not  a  few,  this 
alone  is  sufficient.  In  the  majority  of  cases,  it  is  necessary  to 
begin  with  the  mildest  of  tonic  measures,  increasing  the  vigor  - 
ousness  of  the  treatment  as  the  patient  develops  the  ability  to 
react. 

The  following  are  the  principal  tonic  measures  in  the  order 
of  their  severity.  Taken  one  after  another,  they  may  be  said 
to  constitute  a  therapeutic  ladder. 

1.  WET  HAND    RUB.      A  few  very  anemic  patients  do  not 
possess  sufficient  vitality  to  react  at    first   to    the    cold    mitten 
friction.     These    patients    should   be    given    a   wet    hand   rub 
beginning  with  one  or  two  parts  only,  and  increasing  the  ex- 
tent  of   the    area    treated    as    the    patient's    reactive    powers 
increase.     At    first,  tepid  or  cold  water  may  tax  the  reactive 
powers.     If  so,  the  patient  must  be  rubbed  vigorously  during 
and  following  the  application.     The  temperature  of  the  water 
should  be  decreased  daily  2°  or  3°  F.,  until  cold  water  or  ice 
water  is  used.     Usually,  before  this  point  is  reached,  the  cold 
mitten  friction  may  be  employed. 

2.  COLD    MITTEN   FRICTION.      Begin  with  cold  water,  dip- 
ping the  mitten  once  for  each  part,  and  rubbing  it  vigorously 
until  it  is  well  warmed.     It  should  then  be  dried  and  rubbed 
with  the  dry  hand.     With  each  succeeding  treatment  the  tem- 
perature may  be  lowered  and,  in  a  day  or  two,  the  number  of 
times  the  mitten  is  dipped  for  each  part  may  be  increased  to 


HYDRIATIC  TONICS  263 

two  and  later  to  three  or  four.  When  the  patient  is  able  to 
react  to  ice  water  used  in  this  manner,  other  more  vigorous 
means  may  be  tried. 

3.  COLD  TOWEL  RUB.     This  is  graduated  in  the  same  man- 
ner as  the  cold  mitten  friction.     Since  the  cold  water  is  applied 
to  a  greater  surface  at  one  time,  it  requires  somewhat  greater 
vitality  to  react  to  this  measure. 

4.  PAIL    POUR.     After  the  warm  bath   or   some   other  hot 
treatment,  the  patient  may  receive  to  the  shoulders,  chest  and 
back,  two  or  three  pails  of  water  differing  in  temperature  from  5° 

— 15°  F.  The  first  used  should  contain  water  from  100°— 105°, 
the  second  from  80°— 90°,  and  the  third  from  65°— 80°. 
As  the  patient  shows  ability  to  react  to  these  measures,  the 
temperature  of  the  water  may  be  decreased,  or  additional  pails 
used. 

5.  SALT    GLOW.     This    may  .  be    made  -a   mild   or  extreme 
measure  according  as  fine  or  coarse  salt  is  used,   and  much  or 
little    friction    given.       Since    it    is  not  accompanied  by  cold 
Avater,  it  does  not  severely  tax  the  reactive  powers.     A  pail  pour 
or  shower  may  be  used  to  remove  the  salt  and  so  combine  it 
with  other  tonic  measures. 

6.  COLD  DOUCHE,     This  should  be  preceded  by  a  warm  or 
hot  shower,  or  it  may  be  given  as  a  hot  and  cold   douche  con- 
sisting of  three  or  four  changes.     The  reaction  is  enhanced  by 
the  use  of  percussion.     At  first  only  a  limited  portion  of  the 
body  should  be  treated  in  this  manner,   such  as  the  feet  and 
legs,  later  the  spine  and  chest  also. 

7.  WET  SHEET  RUB.     The  patient  should  stand  in  a  tub  of 
hot  water.     At  first  the  sheet  should  be  wrung  nearly  dry  from 
cold  water.     This  is  wrapped  about  the  patient  in  the  manner 
directed    under  technique.     The    rubbing  should  be  over  the 
sheet  until  the  skin  is  warm  and  then  the  patient  quickly  dried 
by  means  of  sheets  and  towels.     Later,  colder  water  should  be 
used  and  the  sheet  wrung  less  'thoroughly. 

8.  DRIPPING    SHEET    RUB.     When  the  patient  has  acquired 
the  ability  to  react  to  the  wet  sheet  rub,  the   treatment  may 
be  increased  in  vigor  by   pouring    over   the  shoulders    while 


264  STIMULANTS  AND  TONICS 

the  patient  is  still  wrapped  in  the  sheet  and  after  he  has 
been  warmed  by  rubbing,  from  one  to  three  pails  of  cold  water, 
at  first  using:  one  containing  cool  water,  and  later  two  or  three- 
pails  of  colder  water.  After  each  pour,  the  rubbing  should  be 
renewed  and  continued  until  the  patient  is  warm. 

9.  SHALLOW    BATH.     A    full    length  tub  should    be    partly 
filled  with  cold  water.     The  patient  then  enters  the  tub,  sitting- 
upright  while  both  patient  and  attendant  rub  the  limbs  and 
hips.     The  patient  now  reclines  in  the  tub  while  he  is  again 
rubbed   with    cold  water,    it  being  dashed  up  over  the  body 
during  the  course  of  the  rubbing.     The   water  should  hardly 
more   than  half  cover    the    body.      The    temperature    of   the 
shallow  bath  may  be  gradually  decreased. 

10.  COLD    PLUNGE.     This  measure  may  be    considered   the 
last  round  of  the  ladder.     By  active  swimming  movements,  the 
patient  should  promptly  react  to  a  plunge  in  cold  water  at  80° 
— 85°  F.,  and  later  to  much  lower  temperatures.      The  plunge 
bath    should   not   be    continued    long.       At    first    one    or   two 
minutes  only   are  sufficient.     Later,  five,  ten,  or  even  fifteen 
minutes  may  profitably  be  spent  in  swimming.1 

We  have  already  mentioned  that  there  are  a  large  number  of 
conditions  in  which  tonic  measures  are  indicated.  In  some, 
however,  it  is  necessary  to  provide  a  special  course  of  tonic 
treatment.  The  following  is  a  partial  list  of  such  conditions. 
A  few  of  these  will  be  considered  somewhat  at  length. 

Indications  for  Special  Tonic  Treatment. 

1.  Anemia. 

2.  Neurasthenia. 

3.  Melancholia  and  hypochondria. 

4.  Hysteria. 

5.  Dyspepsia. 

6.  Insomnia. 

7.  Chronic  inebriety. 

8.  Chronic  articular  rheumatism. 

9.  Pulmonary  tuberculosis. 

10.  Valvular  heart  disease  and  obesity  with  fatty  heart. 

1    For  more  complete  details  of  these  treatments  see  technique. 


ANEMIA  265 

11.  Diabetes. 

12.  Cerebral  congestion  due  to  sunstroke. 

13.  Multiple  neuritis   (chronic  stage). 

14.  Locomotor  ataxia. 

15.  Hemiplegia. 

In  the  three  last  conditions  the  treatment  should  partake 
more  of  the  nature  of  a  true  stimulant,  as  extreme  measures 
are  necessary  to  provoke  activity  in  atrophied  nerve  structures. 

ANEMIA 

Under,  this  heading-  we  include  the  various  forms  of  second- 
ary anemia.  Primary,  idiopathic,  or  pernicious  anemia  should 
be  treated  along  much  the  same  lines.  As  far  as  possible,  all 
known  causes  should  be  removed.  Irrespective  of  the  many  ulti- 
mate causes  of  anemia,  this  state  is  due  to  deficient  activity  of 
the  blood-making  organs  or  increased  rapidity  in  the  destruc- 
tion of  the  red  cells.  There  is  one  factor  that  is  an  almost 
constant  accompaniment  of  anemia.  This  factor  is  defective 
digestion  and  malassimilation.  Because  of  bad  food,  gastro-in- 
testinal  infections  and  putrefactions,  the  body  may  be  unable 
to  digest  and  appropriate  from  the  food  the  elements  needed  to 
sustain  the  system.  It  is  not  only  the  blood  that  is  deficient, 
but  the  entire  system  is  impoverished.  Therefore,  one  of  the 
chief  objects  to  be  attained  is  improvement  in  digestion  and 
assimilation.  Without  this,  all  other  treatment,  no  matter  how 
good  in  itself,  will  be  an  almost  total  failure.  The  body  may 
be  given  a  more  than  sufficient  supply  of  iron  without  the 
slightest  effect,  unless  the  digestion  and  assimilation  are  im- 
proved by  appropriate  treatment. 

Artificial  preparations  of  iron  nearly  always  derange  the 
digestion  and  so  lessen  the  absorption  of  all  nutriment,  iron 
included.  Preparations  of  iron,  from  Blaud's  pill  to  the  bad 
blood  arid  marrow  of  slaughter-house  animals,  are  all  alike 
unnecessary  in  the  treatment  of  anemia.  The  amount  of  or- 
ganic iron  contained  in  ordinary  foods  is  abundantly  sufficient 
to  supply  the  hematogenic  organs  with  the  necessary  amount 
for  the  formation  of  the  normal  per  cent  of  hemoglobin.  Prof. 
G.  von  Bunge 2  tells  us  that  the  yolk  of  eggs  contains  a  stable 

2    Physiological  and  Pathological  Chemistry,  Second  English  Edition,  p.  375   . 


266  STIMULANTS  AND  TONICS 

organic  compound  of  iron  with  neuclein  and  that  this  compound 
is  doubtless  an  immediate  precursor  of  hemoglobin.  So  effi- 
cient is  this  in  the  formation  of  hemoglobin  that  he  proposes  to 
call  it  the  "blood  former"  (hematogen).  The  fresh  green 
vegetables,  fruits,  grains,  and  nuts  contain  considerable 
amounts  of  organic  iron.  Asparagus  and  spinach  contain  from 
20  to  nearly  40  milligrams  of  organic  iron  to  100  grams  of  dry 
substance.8  Ten  milligrams  or  1-6  grain  of  iron,  the  daily 
amount  required  by  an  adult,  would  be  contained  in  four  ounces 
of  the  yolk  of  egg.  Moreover,  this  iron  is  in  a  form  to  be 
most  easily  digested,  and  most  fully  absorbed. 

It  is  thus  amply  demonstrated  that  inorganic  or  artificial 
preparations  of  iron  are  not  only  entirely  unnecessary,  but  also 
in  many  cases,  positively  injurious,  since  they  derange  the 
digestion.  On  the  other  hand,  the  best  food,  containing  suffi- 
cient organic  iron,  will  not  suffice  to  cure  anemia  if  intestinal 
putrefaction  continues;  and,  through  lack  of  proper  tone  and 
circulation,  the  body  is  unable  to  appropriate  the  food  it 
receives.  In  addition,  then,  to  the  necessity  for  a  simple, 
natural  diet  and  special  attention  directed  toward  improving 
the  digestion,  there  are  two  other  objects  to  be  attained.  First, 
the  blood-making  organs  must  be  stimulated;  second,  the 
circulation  must  be  improved.  That  all  these  results  can  be 
accomplished  by  tonic  hydrotherapy  has  been  demonstrated,  as 
shown  in  the  chapters  on  the  circulation. 

That  tonic  hydrotherapy,  combined  with  a  simple  natural 
diet,  and  outdoor  life,  fresh  air  and  sunshine  is  far  more  effi- 
cient than  iron,  strychnine,  arsenic,"  the  hypophosphites, 
quinine  and  the  like,  is  the  daily  experience  of  those  who 
systematically  employ  physiologic  m^ans.  It  has  yet  to  be 
proven  that  arsenic  has  any  effect  on  the  blood  but  to  impov- 
erish it.  That  it  lessens  both  the  per  cent  of  red  cells  and  of 
•  hemoglobin,  when  regularly  administered,  has  been  amply 
proven.  In  searching  for  experimental  data  concerning  any 
positive  benefit  that  may  be  derived  from  the  administration  of 
arsenic,  one  is  struck  with  the  paucity  of  evidence  along  this 
line.  We  are  asked  to  rely  upon  very  vague  assumptions, 

3    Bunge— Physiological  and  Pathological  Chemistry.  Second  English  Edition,  p.  376. 


ANEMIA  267 

mostly  empirical  in  nature.  We  have  frequently  treated  cases 
of  profound  anemia  in  which  the  whole  picture  was  that  of 
chronic  arsenic  poisoning-  rather  than  simple  anemia,  the 
arsenic  having  been  administered  to  cure  the  anemia. 

In  the  hydriatic  management  of  anemia,  it  is  necessary  to 
provide  a  carefully  graded  system  of  tonic  treatment.  In  the 
extreme  forms  of  anemia,  the  beginning-  must  be  at  the  bottom 
round  of  the  ladder  of  tonic  measures.  Each  application  of 
cold  should  be  preceded  by  a  short  hot  application,  such  as 
fomentations  to  the  spine  or  abdomen,  the  hot  foot  bath,  or 
local  electric  light  bath.  No  long-  hot  treatments  should  be 
used  since  the  vitality  is  so  much  reduced  as  to  illy  bear  the 
depression  occasioned  by  sweating.  However,  all  forms  of 
local  applications  of  heat  are  indicated  in  anemia.  Following 
one  or  more  short  moderately  hot  applications,  the  patient 
should  be  given  a  wet. hand  rub,  cold  mitten  friction  or  cold 
towel  rub,  according-  to  his  ability  to  react.  This  should  be 
repeated  about  twice  daily,  or  a  light  massage  may  be  given 
once  a  day.  Later  on,  -as  the  circulation  improves,  the  patient 
may  be  treated  by  the  cold  towel  rub,  hot  and  cold  to  the  spine, 
and  still  later,  alternate  hot  and  cold  douches  and  sprays. 
Advancement  in  the  tonics  should  be  made  slowly.  It  may 
take  several  weeks  for  the  patient  to  acquire  sufficient  vitality 
to  react  to  a  g-eneral  shower  bath.  The  salt  glow  may  be  used 
before  the  more  vigorous  cold  applications  can  be  borne. 
Following  this,  may  be  used  the  general  affusion  or  pail  pour, 
at  first  of  warm  or  tepid  water,  later  of  cool  and  cold  water. 
After  some  weeks  a  short  full  electric  light  bath  may  be  given, 
followed  by  a  vig-orous  hot  and  cold  spray.  When  this  point 
has  bsen  reached,  advance  may  be  made  more  rapidly,  using 
the  wet  sheet  rub,  dripping-  sheet  rub,  cold  shallow  bath,  and 
the  cold  plunge. 

Massage  is  especially  indicated  in  anemia  before  the  patient 
is  able  to  take  much  exercise.  The  manipulation  should  be 
what  is  termsd  "general  massage;"  i.  e.,  it  should  combine  all 
of  the  procedures  usually  given  in  Swedish  massage.  Of  spec- 
ial importance  are  the  movements  of  deep  kneading.  After  a 
single  massage  lasting  forty-five  to  sixty  minutes,  the  red  cells 


268  STIMULANTS  AND  TONICS 

frequently  show  a  gain  of  25  to  50  per  cent  and  may  even  be 
doubled  in  number.  These  gains  are  of  course  not  permanent 
but  they  last  longer  and  longer  as  the  treatments  are  repeated. 
The  hemoglobin  per  cent  rises  more  slowly  than  the  red  cells. 

Full  sun  baths  are  especially  beneficial.  The  scientific  basis 
for  the  use  of  the  sun  bath  in  anemia  and  chlorosis  has  been 
well  demonstrated  experimentally.4  Exposure  to  sunlight  in- 
creases the  oxygen-carrying  capacity  of  the  red  blood  cells.  It 
stimulates  hematogenesis,  increasing  both  the  number  of  red 
cells  and  the  hemoglobin  per  cent.  It  is  a  fundamental  proto- 
plasmic stimulant.  It  hastens  cell  division  and  cell  growth. 
It  is  a  most  effective  stimulant  to  the  peripheral  circulation. 
Pure,  fresh  air  supplies  the  needed  oxygen  that  makes  possible 
the  best  results  from  the  sunlight.  ' '  Zuntz  and  his  school  have 
shown  that  the  effects  of  mountain  air  are  apparent,  not 
only  in  their  influence  on  red  corpuscles,  but  also  on  the  nitro- 
genous metabolism  of  the  body  as  a  whole,  so  that  there  is  in 
most  individuals  a  positive  nitrogen  balance,  an  actual  repro- 
duction of  the  conditions  found  in  the  growing  organism."  5 

An  Anglo-American  expedition  to  Pike's  Peak  in  the  sum- 
mer of  1911  confirmed  the  claims  of  European  observers  in  the 
Alps  relative  to  the  effect  of  high  altitudes  upon  the  blood. 
They  found  a  large  increase  in  red  cells,  hemoglobin,  and  white 
cells.6  The  red  cells  increased  30  to  40  per  cent  and  the  hemo- 
globin kept  pace  with  it.  On  descent  it  required  about  four 
weeks  for  the  excess  of  hemoglobin  to  disappear.  These  ob- 
servers claim  that  the  lungs  develop  a  capacity  to  secrete  oxy- 
gen from  the  alveolar  air  into  the  blood. 

The  effects  of  sunlight  and  out-door  life  among  natural  sur- 
roundings are  apparent  not  alone  in  the  physical  changes  they 
induce,  but  also  in  the  psychic  improvement  of  the  patient. 
When  proper  attention  is  given  to  all  of  the  items  mentioned, 
also  to  digestion  (see  dyspepsia)  the  maximum  good  may  be 
obtained. 


4  Cleaves— Light  Energy,  pp.  271.  322. 

5  Starling— Fluids  of  the  Body,  p.  142. 

6  DouKlass.  Hendane,  Henderson  and  Schneider:    The  Physiologic  Effects  of  Low  At- 
"s'"c  fissures,  as  Observed  on  Pike's  Peak.  Colorado;  Proc.  Roy.  Soc.  London  (B). 

\t  65. 


NEURASTHENIA  269 

NEURASTHENIA 

The  management  of  neurasthenia  by  systematic  hydrotherapy 
has  been  so  universally  successful  that  it  is  now  regarded  by 
neurologists  as  indispensable  in  the  treatment  of  this  condition. 
Moreover,  the  necessity  for  change  of  environment  and  efficient 
training  of  the  patient  in  proper  habits  of  diet,  rest,  exercise, 
etc.,  demand  that  for  a  time,  at  least,  this  be  carried  on  in  an 
institution  fully  equipped  with  the  necessary  appliances  and 
manned  with  physicians  and  attendants  trained  in  hydriatic 
technique. 

The  manifestations  of  nerve  exhaustion  are  exceedingly  pro- 
tean. For  this  reason,  individualization  is  perhaps  more  im- 
perative in  this  than  in  any  other  disorder.  It  is  necessary  to 
carefully  observe  the  effects  of  each  treatment.  While  the  state- 
ments of  the  patient  in  regard  to  these  effects  are  not  a  suffi- 
cient guide,  they  should  not  be  wholly  disregarded.  It  may  be 
necessary  to  make  several  changes  before  the  most  suitable 
measures  have  been  settled  upon.  A  mere  training  in  tech- 
nique is  not  all  that  is  necessary  for  the  physician  to  acquire. 
He  should  be  thoroughly  conversant  with  the  scientific  basis 
of  physiologic  effects,  by  close  observation  adapting  these  to 
the  needs  of  the  patient  as  experience  shall  direct. 

The  psychic  element  plays  such  a  large  part  that,  in  case  the 
patient  takes  a  violent  dislike  to  some  procedure,  not  absolutely 
essential,  it  is  best  to  substitute  another  of  similar  effect.  We 
commonly  encounter  the  idea  that  frequent  baths  are  weaken- 
ing. It  is  no  small  task  to  disabuse  the  mind  of  this.  This 
and  other  imagined  dangers  are  very  real  to  the  mind  of  the 
patient.  Often,  they  may  be  overcome  by  utilizing  some  other 
notion  as  a  placebo.  We  have,  however,  found  straight-for- 
ward education  the  best  all-around  plan.  This  requires  a 
great  deal  of  time  on  the  part  of  the  physician,  but  the  efforts 
are  often  well  repaid  in  the  long  run. 

The  neurasthenic  state  is  almost  invariably  associated  with 
faulty  digestion.  The  digestive  derangement  maybe  a  large 
cause,  a  contributing  factor  or  a  result  of  the  nerve  exhaustion. 

Where  defective  digestion  is  a  prominent  feature,  special 
measures  should  be  directed  toward  restoration  of  the  normal 


270  STIMULANTS  AND  TONICS 

function.     The  treatment  of  dyspepsia  is  considered  in  another 
place. 

The  overworking  of  any  organ  or  function  leads  to  exhaus- 
tion. The  chief  cause  of  nerve  exhaustion  lies  in  overactivily 
of  the  brain  and  nerves,  accompanying  deficient  physical  activ- 
ity. Neurasthenia  may,  however,  occur  in  an  individual  who 
is  engaged  in  an  occupation  requiring  constant  bodily  activity. 
Worry,  grief,  disappointment — financial  or  social — these  all  have 
their  place  in  the  causation  of  nerve  exhaustion.  A  compre- 
hensive view  of  the  disease  and  its  causes  reveals  the  necessity 
for  two  classes  of  physiologic  effects,  viz.,  tonic  and  sedative: 
sedative,  to  assist  in  securing  rest,  the  most  essential  element 
in  building  up  lost  nerve  force;  tonic,  to  restore  normal  nerve 
activity  and  hasten  the  building  up  process.  No  hard  and  fast 
lines  may,  however,  be  drawn  between  procedures  directed  to 
these  ends.  Tonic  measures  are,  of  course,  in  the  long  run 
conducive  to  normal  rest,  but  they  may  also  be  immediately 
sedative  in  their  effects.  This  peculiar  paradox,  that  tonic 
measures  produce  sedation  and  sedative  measures  are  tonic, 
exists  only  in  the  realm  of  physiologic  therapy.  One  would 
not  pick  upon  the  bromides  to  restore  the  normal  nerve  tone  or 
upon  strychnine  to  produce  rest  or  sleep.  The  special  treat- 
ment of  insomnia  and  the  irritative  neurasthenic  state  will  be 
considered  more  at  length  under  sedative  effects  (q.  v.). 

In  beginning  the  treatment  of  a  neurasthenic  patient,  it  is 
well,  at  first,  to  test  the  reactive  powers  by  mild  measures 
which  will  produce  no  shock.  Since  first  impressions  are  often 
very  lasting,  the  initial  treatment  may  consist  of  such  forms  of 
the  bath  as  are  not  greatly  different  from  those  used  at  home. 
This  serves  to  make  the  patient  acquainted  with  the  attendant 
and  the  attendant  with  some  of  the  pecularities  of  the  patient. 
The  full  warm  tub  bath  and  tub  shampoo,  finished  with  a  warm 
•and  then  a  cool  pail  pour  serves  this  purpose  for  a  large  num- 
ber of  patients.  Since  nearly  all  neurasthenics  complain  of 
cold  feet  and  more  or  less  abdominal  distress,  we  frequently 
use  the  hot  foot  bath  with  fomentations  to  the  abdomen.  This 
may  be  made  the  second  treatment  and  concluded  with  a  wet 
hand  rub  or  cold  mitten  friction.  With  this,  or  following 


NEURASTHENIA  271 

closely,  we  utilize  hot  and  cold  to  the  spine,  the  revulsive  com- 
press, the  pail  pour,  salt  glow,  and  graduated  spray.  Later, 
after  considerable  reactive  capacity  has  been  developed,  the 
cold  towel  rub  and  wet  sheet  rub  may  be  used.  The  alternate 
spray,  alternate  douche,  and  shallow  bath  are  quite  vigorous 
means  and  should  not  be  ventured  upon  in  the  agitative  form 
of  neurasthenia,  or  not  until  milder  tonics  have  been  used  for 
some  time. 

The  wet  sheet  pack,  although  an  excellent  tonic,  as  well  as 
sedative  means,  is  often  objected  to  by  the  neurasthenic.  He 
complains  that  it  makes  him  nervous,  he  feels  restrained,  etc. 
The  sitz  bath  at  the  various  temperatures  at  which  it  may  be 
used,  is  capable  of  most  excellent  results.  For  this  purpose  the 
tub  must  be  deep  enough  so  that  the  water  will  cover  the 
greater  part  of  the  abdomen.  Provided  there  are  no  local 
conditions  requiring  treatment,  the  sitz  tub  may  first  be  filled 
with  water  at  98°  which  is  gradually  raised  to  102°  or  103°  and 
then  lowered  to  90°  or  85°  just  before  the  close,  or  it  may  be 
concluded  with  a  cold  pail  pour  to  the  hips  (revulsive  sitz). 
The  second  bath  may  be  begun  at  98°  or  95°  and,  without  rais- 
ing the  temperature  of  the  water,  gradually  lowered  to  85°  or 
80°.  On  each  succeeding  day,  it  is  begun  at  a  slightly  lower 
temperature  and  finished  with  colder  water,  until  it  is  essen- 
tially a  prolonged  cold  sitz.  The  bath  acts  by  reducing  the 
blood  supply  to  the  abdomen  and  pelvis,  decongesting  the 
abdominal  and  pelvic  sympathetic^  and  restoring  their  tone.  It 
aids  in  the  relief  of  general  splanchnoptosis. 

About  once  a  week  the  patient  should  be  given  a  short 
electric  light  bath  followed  by  a  spray,  or  shampoo  and  spray. 
The  electric  light  bath  should  be  three  or  four  minutes  in 
length,  sufficient  to  thoroughly  warm  the  skin  and  produce 
beginning  perspiration. 

The  old  idea  that  the  melancholic  state  is  due  to  liver 
derangement  (black  bile)  is  not  wholly  without  foundation. 
Wrong  habits  of  diet,  together  with  constipation,  are  large 
factors  in  the  production  of  the  depressed  type  of  neurasthenia. 
Both  of  these  crowd  the  liver  with  toxins  and  products  of 
imperfect  digestion.  An  overworked  liver  in  time  becomes 


272  STIMULANTS  AND  TONICS 

a  sluggish,  torpid  liver,  incapable  of  performing"  its  functions 
as  a  toxin  destroyer  and  emunctory.  In  addition  to  general 
treatment  and  treatment  directed  toward  the  relief  of  indiges- 
tion and  constipation,  we  have  found  alternate  hot  and  cold 
applications  to  the  hepatic  area  of  special  advantage.  The 
revulsive  compress,  alternate  hot  and  cold,  and  especially  the 
alternate  hot  and  cold  percussion  douche  to  the  liver  should  be 
used  frequently. 

For  cerebral  congestion  nothing  is  superior  to  the  alternate 
hot  and  cold  foot  bath  or  the  alternate  percussion  douche  to  the 
feet.  The  latter  may  be  preceded  by  a  short  hot  leg  pack  or 
hot  leg  bath  with  cold  compresses  to  the  head  and  neck. 

The  work  cure  for  neurasthenia  has  been  successful  in  the 
hands  of  a  few  physicians  who  have  formulated  a  definite  plan 
for  such  treatment.  That  which  has  been  reported  is  largely 
in  the  line  of  indoor  work.  Much  more  successful  is  the  use 
of  gardening,  floriculture  and  horticulture  to  employ  the  time 
and  occupy  the  thoughts  of  the  neurasthenic  patient.  These 
occupations  take  him  out  into  the  fresh  air  and  sunshine,  and 
to  the  extent  he  can  be  interested  in  "  helping  things  grow," 
just  to  that  extent  the  success  of  the  plan  is  assured. 

It  has  also  been  shown  by  Pansini 7  that  the  actinic  rays  of 
sunlight  or  artificial  light  increase  muscular  capacity,  while 
red  light  has  the  opposite  effect.  Red  light,  of  course,  consists 
largely  of  thermic  frequencies  and  hence  its  effect  is  essentially 
that  of  heat.  Blue  light  (actinic  ray)  increases  both  the  am- 
plitude and  number  of  contractions  as  shown  by  ergograms. 

In  a  control  test  the  muscles  were  able  to  lift  1.736  kilograms; 
before  recovering  from  the  fatigue  of  this  test,  they  lifted  1.455 
kilograms;  and  after  the  exposure  to  the  light  of  a  blue  lamp, 
the  total  of  the  curve  showed  1.848  kilograms,  indicating  not 
only  the  recovery  from  fatigue  but  a  gain  of  .112  kilograms 
'  over  the  capacity  of  the  unfatigued  muscles. 

The  general  program  and  the  distribution  of  the  treatments 
during  the  day  are  of  importance. 

It  will  be  found  that  the  best  results  are  obtained  by  one  tonic 
treatment  a  day.  A  short  sedative  treatment  may  be  given  in 

7    Cleaves— Light  Energy,  pp.  301-303. 


SPLANCHNIC  NEURASTHENIA  273 

the  afternoon  or  at  night.  If  more  than  this  is  used,  the 
afternoon  treatment  may  consist  of  massage  or  electricity  in 
some  form.  Too  continuous  a  round  of  treatment  limits  the 
time  for  rest  and  out-of-door  life  and  recreation,  which  are  all 
important  in  neurasthenia.  It  is  a  mistake  to  allow  the  patient 
to  insist  upon  local  applications  three  or  four  times  a  day  for 
local  distresses,  such  as  "  backache  "  or  "  indigestion."  They 
only  serve  to  more  firmly  fix  the  patient's  attention  upon  some 
minor  ailment,  and  confirm  his  introspective  tendencies. 

The  measures  and  plan  outlined  above,  when  given  under 
careful  supervision  and  combined  with  regulation  of  diet,  exer- 
cise, rest,  etc.,  will,  if  proper  psychic  control  be  not  neglected, 
invariably  result  in  the  recovery  of  the  neurasthenic  patient. 

SPLANCHNIC  NEURASTHENIA 

In  many  neurasthenic  patients  the  distressing  symptoms  cen- 
ter about  the  abdomen.  There  is  a  feeling  of  weight  and  ex- 
haustion accompanied  by  mental  depression.  The  exacerba- 
tions of  this  state  have  not  inaptly  been  styled  "  the  blues,"  as 
the  exciting  causes  are  worry,  disappointment,  and  such  like 
nervous  disturbances,  which  give  rise  to  a  temporary  melan- 
cholia. The  predisposing  factors  entering  into  this  condition 
are  constipation,  auto-intoxication,  dyspepsia,  general  nerve 
exhaustion,  insufficient  physical  exercise,  etc. 

The  immediate  physical  basis  of  splanchnic  neurasthenia  lies 
in  an  engorgement  of  the  splanchnic  blood-vessels,  particularly 
of  the  veins.  These  vessels  are  capable  of  great  distension 
when  the  vasomotors  are  rendered  paretic  through  intestinal 
auto-intoxication,  worry,  grief,  etc.  A  very  rational  plan  of 
treatment,  as  far  as  this  condition  is  concerned,  is  advised  by 
Abrams.8  This  consists  of  various  means  intended  to  increase 
the  abdominal  tension  and  stimulate  the  splanchnic  vasomotors 
for  the  purpose  of  relieving  the  visceral  stasis  of  blood,  and  by 
means  of  a  quickened  splanchnic  blood  current,  especially  in 
the  liver,  directly  increasing  the  hepatic  destruction  of  poisons 
and  hastening  their  elimination. 

Abrams  especially  favors  the  use  of  the  sinusoidal  current  for 

8    The  Blues;  also  Spondylotherapy. 
18 


274  STIMULANTS  AND  TONICS 

this  purpose.  Applied  by  means  of  a  stationary  spinal  electrode 
and  a  labile  abdominal  sponge,  the  treatment  is  certainly  most 
effective.  The  abdominal  muscles  are  powerfully  stimulated 
by  the  slow  sinusoidal  current,  thus  increasing  intra-abdominal 
pressure,  but  the  greatest  effect  is  upon  the  splanchnic  vaso- 
motors  reflexly. 

These  patients  experience  much  relief  by  assuming  the  hori- 
zontal position.  The  movement  of  "  inspiratory  lifting,"  as 
carried  out  in  abdominal  massage,  also  affords  instant  relief. 
The  use  of  abdominal  supporters,  and  the  application  of  broad 
bands  of  adhesive  plaster  to  the  abdomen,  in  splanchnoptosis 
and  splanchnic  neurasthenia  give  relief  as  long  as  they  are  in 
place.  Both  these  means,  however,  ultimately  result  in  weak- 
ening the  abdominal  muscles,  and  so,  unless  accompanied  by 
other  treatment,  defeat  their  own  purpose.  Where  it  is  at  all 
possible  to  strengthen  the  abdominal  muscles,  it  is  better  to 
adopt  some  system  of  exercises  especially  calculated  to  develop 
them. 

Of  hydriatic  means,  the  following  combination  is  especially 
efficacious  in  splanchnic  neurasthenia  for  the  purpose  of  decreas- 
ing the  splanchnic  congestion.  A  hot  foot  bath  with  the  cold 
Winternitz  coil  to  the  abdomen  and  cold  compresses  to  the  head 
and  neck,  continued  for  from  twelve  to  twenty  minutes,  is  the 
first  part.  A  cold  sitz  of  four  to  six  minutes  duration  follows, 
and  the  treatment  is  concluded  by  a  wet  sheet  rub.  This  is 
especially  adapted  to  warm  weather.  During  the  winter  months 
it  may  be  necessary  to  apply  more  heat.  With  less  vigorous 
patients,  the  first  combination  of  hot  foot  bath  with  cold  coil  to 
the  abdomen  and  cold  compresses  to  the  head  may  be  continued 
thirty  minutes  or  longer,  and  concluded  with  a  cold  mitten 
friction.  These  cold  applications  to  the  abdomen  and  pelvis 
produce  decided  and  prolonged  contraction  of  the  visceral  blood- 
vessels. The  fan  douche  to  the  hepatic  region  and  abdomen 
also  accomplishes  much  the  same  results. 

HYSTERIA 

While  some  cases  require  a  greater  proportion  of  sedative 
treatment,  nearly  all  require  more  or  less  of  tonic  treatment. 


TUBERCULOSIS  275 

The  chief  result  to  be  obtained  by  tonic  treatment  is  the  restora- 
tion of  tone  to  the  neurons,  so  that,  by  training-,  self-control 
becomes  possible.  The  methods  outlined  for  neurasthenia  are 
all  applicable  in  hysteria. 

DYSPEPSIA 

The  special  treatment  necessary  in  this  condition  will  be  con- 
sidered later,  but  local  measures  unaccompanied  by  general 
tonic  treatment  are  often  insufficient  to  accomplish  full  return 
to  health.  The  measures  recommended  for  anemia  and  those 
necessary  in  neurasthenia  are  all  applicable  in  altered  states  of 
the  dig-estion. 

PULMONARY   TUBERCULOSIS 

The  recovery  from  pulmonary  tuberculosis  is  essentially  a 
matter  of  vital  resistance.  Hence,  efficient  treatment  resolves 
itself  into  means  for  the  promotion  of  this  vital  resistance  and 
the  improvement  of  nutrition.  These  means  are  fresh  air,  sun- 
shine, and  diet,  together  with  other  measures  which  have  tonic 
effects.  Although  early  tuberculosis  has  proven  one  of  the 
most  curable  diseases  by  these  hygienic  methods,  yet  no  hard 
and  fast  lines  can  be  laid  down  for  their  employment  in  indi- 
vidual cases.  The  exercise  of  enlightened  and  scientific  com- 
mon sense  is  especially  necessary  in  dealing  with  this  disease. 
Not  all  patients  can  eat  the  same  thing.  While  milk  and  eggs 
may  form  a  sort  of  dietetic  center  for  the  improvement  of  nutri- 
tion, yet  these  must  be  intelligently  used;  nor  should  other 
articles,  such  as  cereals  and  fruits,  be  neglected.  The  latter 
.  are  especially  useful  in  maintaining  the  alkalinity  of  the  blood 
and  improving  urinary  elimination.  The  nutrition  may  be 
pushed  by  a  milk  diet  in  some  cases  with  most  excellent  results, 
while  other  patients  do  not  bear  this  method  well.  Like  all 
exclusive  methods,  if  used,  it  should  be  for  a  limited  time  only 
and  for  the  accomplishment  of  certain  results ,  return  then  being 
made  to  a  more  general  diet,  by  which  only  all  the  needs  of 
nutrition  can  be  permanently  met.  The  tuberculous  patient 
requires  as  careful  dietetic  treatment  as  that  given  to  the  patient 
with  a  gastric  or  intestinal  disorder  only. 


276  STIMULANTS  AND  TONICS 

In  regard  to  fresh  air,  it  must  be  insisted  that  nothing-  less 
than  twenty-four  hours  of  outdoor  air  will  accomplish  the  best 
results.  This  means  that  proper  sleeping-  arrang-ements  should 
be  provided,  so  that  fog-  and  dampness  will  not  interfere  in 
climates  where  these  are  prevalent.  Of  course,  if  possible,  a 
change  should  be  made  to  a  dry  climate.  Whether  this  should 
be  a  warm  or  a  cold  dry  climate,  a  moderately  high  or  a  low 
altitude,  will  depend  upon  the  stage  of  the  disease  and  upon  the 
needs  of  the  individual  case.  An  altitude  of  4000  to  6000  feet 
is  beneficial  to  those  who  are  not  nervous,  and  when  heal- 
ing in  the  lung  has  progressed  sufficiently  to  be  assisted  by  the 
lung  gymnastics  of  deep  breathing. 

The  patient  with  a  rise  of  temperature  above  100°  should 
observe  complete  rest.  With  the  temperature  between  99°  and 
100°,  complete  rest  is  not  necessary;  the  patient  may  be  up  and 
about,  but  rest  is  still  the  rule.  The  full  sun  bath — direct  ex- 
posure of  the  entire  skin  surface  to  the  sunlight — is  the  most 
beneficial  form  of  light  therapy.  The  Kime  or  other  reflector 
for  the  concentration  of  actinic  rays  upon  the  chest  is  a  very 
useful  means  of  promoting  healing.  The  sun  bath  improves 
the  nutrition,  increases  cell  division  and  growth,  stimulates 
hematogenesis,  and  increases  oxidation.  It  stimulates  capillary 
circulation,  so  as  to  do  away  with  the  symptoms  of  poor  circu- 
lation— cold  hands  and  feet.  It  improves  the  psychic  condition 
of  the  patient,  a  result  which  is  not  to  be  lightly  esteemed. 

In  regard  to  hydriatic  tonics,  we  must  caution  the  physician 
against  anything  but  those  of  a  very  mild  nature.  Fomenta- 
tions to  the  various  portions  of  the  body,  together  with  the  cold 
mitten  friction,  is  all  that  we  have  found  beneficial.  General 
tonic  baths,  sprays,  and  douches  had  best  be  omitted  entirely. 
Of  course  these  may  be  used  in  building  up  the  resistance  of 
one  who  has  recovered,  but  they  are  not  to  be  used  in  the 
treatment  of  the  disease.  Fomentations  to  the  chest  are  useful 
in  the  treatment  of  pleurisy  and  the  relief  of  pain,  drawing,  and 
other  abnormal  sensations.  The  cold  mitten  friction  is  also 
one  of  the  best  means  of  checking  night  sweats.  Its  action  is 
directly  upon  the  vasomotor  and  secretory  nerves.  But  back 
of  this,  by  its  tonic  effect,  it  helps  to  do  away  with  the  as- 


CHRONIC  INEBRIETY  277 

thenia,  which  is  the  ultimate  cause  of  the  excessive  sweating. 
Altogether  the  general  hygienic  management  of  tuberculosis 
by  fresh  air,  sunshine,  and  ample  feeding,  is  of  greater  impor- 
tance than  hydrotherapy,  which  occupies  a  minor  but  helpful 
place  in  its  treatment. 

INSOMNIA 

Treatment  of  this  condition  will  be  considered  under  seda- 
tive effects.  A  large  number  of  cases  occurring  in  business 
or  professional,  men  may  be  treated  almost  wholly  by  tonic 
measures,  since  normal  fatigue  is  lacking  because  of  insufficient 
exercise.  Tonic  treatment  is  directed  toward  the  production  of 
moderate  fatigue,  so  that  sleep  may  be  induced  as  a  natural 
consequence.  The  tonic  measures  listed  at  the  first  of  this 
chapter  are  nearly  all  applicable  in  this  condition,  and  should 
be  accompanied  by  active  exercise  in  the  open  air. 

CHRONIC  INEBRIETY 

In  chronic  alcoholic  poisoning  the  tissues  are  in  a  state  of 
lessened  activity.  Alcohol  circulating  in  the  system  for  months 
or  years  tends  to  harden  the  tissues,  causing  an  over-production 
of  fibrous  connective  tissue  and  lessening  the  activity  of  par- 
enchymatous  cells.  In  order  to  overcome  this  partial  pickling 
process,  it  is  necessary  to  use  the  most  extreme  measures,  such 
as  extreme  hot  and  cold,  to  wake  up  the  deadened  tissues, 
especially  the  brain  and  nervous  system.  Immediately  follow- 
ing a  spree,  measures  should  be  directed  toward  the  rapid 
elimination  of  the  alcohol  imbibed.  If  the  patient  is  still  under 
the  influence  of  the  liquor,  he  may  be  held  under  the  cold 
shower  to  stimulate  the  nerves  and  hasten  the  circulation. 
After  the  immediate  danger  is  passed,  he  should  be  given  full 
hot  tub  baths  or  the  electric  light  bath,  accompanied  by  the 
drinking  of  large  quantities  of  water.  These  measures  hasten 
the  elimination  of  the  alcohol.  Any  hot  treatment  should  be 
followed  by  the  hot  and  cold  spray  or  shower.  The  hot  and 
cold  douche  is  an  excellent  means  of  stimulating  activity.  In 
those  cases  that  have  been  very  much  reduced  by  long  years  of 
dissipation,  it  may  be  necessary  to  employ  milder  measures, 


278  STIMULANTS  AND  TONICS 

such  as  the  neutral  bath,  the  wet  sheet  pack,  fomentations,  and 
the  cold  mitten  friction. 

CHRONIC  ARTICULAR  RHEUMATISM 
It  is  the  usual  custom  in  gouty  rheumatism  to  employ  ex- 
treme sudorific  measures.  Such  treatment,  unaccompanied  by 
tonic  measures,  is  applicable  only  in  obese  rheumatics,  and  in 
those  cases  only  for  a  limited  time.  While  any  form  of  cold 
treatment  may  temporarily  increase  the  stiffness  and  soreness, 
it  is  quite  essential  that  these  patients  should-  be  given  tonic 
treatment.  The  cold  mitten  friction  is  probably  the  best  meas- 
ure, since  it  quickly  produces  a  reaction  and  can  be  gfiven  to  all 
parts  of  the  body,  avoiding-  the  joints.  Tonic  measures  are 
necessary,  not  only  to  assist  the  heat  in  increasing  the  oxidation 
and  elimination  of  toxines  and  the  surplus  of  nitrogenous  ma- 
terial, which,  by  long  crowding  with  proteid  foods  of  high  purin 
content,  has  become  well  fixed;  but  also  to  increase  the  building 
up  process  and  the  general  body  weight. 

DIABETES 

Diabetes  is  a  condition  in  which  the  system  is  unable  to 
warehouse  and  consume  the  carbohydrate  of  an  ordinary  diet. 
The  disease  may  be  classified  under  two  heads:  First,  an  ali- 
mentary form  in  which  withdrawal  of  carbohydrate  from  the 
diet  for  a  time  produces  a  cure,  i.  e.,  the  body  is  thereafter  able 
to  utilize  a  moderate  amount  of  sugar.  This  is  looked  upon  as 
a  functional  disease,  although,  as  remarked  below,  it  may  be 
due  to  partial  destruction  of  the  ductless  glands  of  the  pancreas. 
Second,  a  permanent  or  organic  diabetes  in  which  excretion  of 
sugar  continues  after  the  withdrawal  of  all  carbohydrate.  It 
has  been  pretty  well  proven  that  destruction  of  the  islands  of 
Langerhans  is  the  causative  lesion  in  the  majority  of  cases. 
.  These  ductless  bodies  are  believed  to  secrete  a  glycolytic  or 
oxidizing  ferment  (oxidase),  which  has  the  ability  to  break  up 
and  oxidize  the  sugar  molecules.  This  occurs  in  the  general 
system,  but  principally  in  the  muscles.  If  about  one-tenth  of 
the  pancreas  remains  intact  after  partial  extirpation,  diabetes 
results  only  on  ingestion  of  carbohydrate.  According  to  Thoinot 


DIABETES  279 

and  Delamere,  Langerhans  insufficiency  is  found  in  about  80 
per  cent  of  cases.  Defect  in  the  glycogenic  function  of  the 
liver  may  also  cause  permanent  diabetes. 

The  usual  treatment  of  diabetes  is  directed  toward  securing 
but  one  end;  viz.,  decreasing  the  excretion  of  grape  sugar  by 
lessening  the  ingestion  of  carbohydrates,  substituting  proteid 
(chiefly  meat),  as  recommended  by  von  Noorden.  Chitten- 
den9  has  recently  shown  that  the  ingestion  of  proteid,  above  a 
certain  minimal  requirement,  which  he  sets  at  about  35  to  60 
grams,  results  in  a  very  few  hours  in  the  excretion  of  practi- 
cally all  the  surplus  nitrogen  in  the  form  of  urea,  the  residue 
being  simple  carbohydrate  not  distinguishable  from  the  carbo- 
hydrate taken  as  such.  Such  a  process  can  hardly  be  said  in 
any  way  to  conserve  the  body  powers.  The  great  amount  of 
useless  labor  demanded  of  the  liver  by  such  a  diet  must  result 
in  overworking  that  organ.  All  this  occurs,  to  say  nothing  of 
the  detrimental  effects  of  flooding  the  system  with  purins  from 
the  large  quantities  of  meat  which  the  von  Noorden  diet  neces- 
sitates. While  temporary  exclusion  of  carbohydrate  from  the 
diet  with  a  gradual  return  to  "a  moderate  ingestion  of  starches 
and  sugars  is  quite  essential  and  an  effective  plan  for  the 
dietetic  management  of  diabetes,  this  alone  does  not  meet  the 
needs  of  the  condition.  The  real  cause  of  the  disease  lies  in 
altered  carbohydrate  metabolism.  The  sugar  passing  through 
unoxidized  causes  a  loss  of  energy  that  should  accrue  from  this 
source.  In  other  words,  the  carbohydrate  fuel  falls  through 
the  grate  before  being  burned,  because  of  lack  of  proper  regu- 
lation of  the  fire.  Lessening  the  amount  of  fuel,  while  a  most 
important  factor  in  treatment,  only  partially  remedies  the  defect. 

The  rational  management  must,  therefore,  aim  at  increasing 
the  oxidation  of  grape  sugar,  and  thereby  preventing  its  elim- 
ination in  an  unoxidized  state  with  the  consequent  energy  loss. 
There  are  no  known  medicinal  agents  or  even  any  mode  of 
dietetic  management  which  will  accomplish  this  result.  Experi- 
ment has  revealed  the  fact  that  nothing  so  greatly  promotes 
oxidative  changes  as  exercise  in  the  fresh  air  and  tonic  hydro- 
therapy.  The  effects  of  these  agents  on  carbonaceous  metabol- 

9    Nutrition  of  Man,  p.  131. 


280  STIMULANTS  AND  TONICS 

ism  we  have  already  considered.  Because  of  the 
lessened  vitality,  and  gfreat  susceptibility  to  fatigue  which  is  an 
almost  constant  accompaniment  of  diabetes,  it  is  often  difficult 
not  to  say  unwise,  in  many  cases  to  pursuade  the  patient  to 
exercise.  When  there  is  much  loss  of  vitality  the  exercise  must 
be  of  a  passive  nature,  /'.  e.,  secured  by  massage.  Massage 
stimulates  the  glycolytic  powers  of  the  muscles,  improves  the 
circulation,  and  aids  nutritive  changes.  More  important  than 
this,  however,  are  the  effects  derived  from  applications  of  cold 
water  accompanied  by  friction  or  percussion.  Cold  frictions, 
cold  douches,  and  mild  alternating  hot  and  cold  applications 
effectually  stimulate  metabolism.  Those  hydriatic  measures 
which  are  accompanied  by  strong  mechanical  stimuli  have 
double  the  effect  of  cold  applications  without  friction  or  percus- 
sion. Cold  douches  have  been  shown  to  increase  oxidation 
more  than  100  per  cent.  These  means  also  improve  the  nutri- 
tion of  the  skin,  and  so  aid  in  preventing  many  of  the  annoying" 
cutaneous  complications. 

Graham  Lusk  reports  a  series  of  experiments  on  the  influence 
of  cold  baths  on  the  glycogen  content  of  man  in  which  he  she  >\vs 
that  extreme  cold  treatment  so  greatly  enhances  oxidation  as  to 
quickly  change  the  aspect  of  combustion  from  support  by  car- 
bohydrates to  support  by  fat.  These  experiments  were  done 
with  normal  individuals.  From  this  report10  we  quote  the  fol- 
lowing:— 

During  the  shivering  which  followed  the  second  cold  bath 
the  metabolism,  as  measured  by  the  heat  production,  was  63 
per  cent  higher  than  during  the  subsequent  resting  period,  but 
the  respiratory  quotient  of  0.75  remained  unchanged  during 
both  periods.  It  is  evident  from  this  experiment  that  the  influ- 
ence of  two  successive  cold  baths,  ivhich  cause  shivering  during  a 
period  when  the  intestine  is  free  from  carbohydrate,  is  sufficient  to 
change  the  metabolism  from  one  maintained  at  the  expense  of  carbo- 
hydrate (R.  Q.=0.99)  to  one  maintained  essentially  by  the  combus- 
tion of  fat  (R.  Q.=0.75}.  Hence  the  organism  of  man  may  be 
quickly  rid  of  glycogen  by  shivering. 

10    The  Influence  of  Cold  Baths  on  the  Glycogen  Content  of  Man.  American  Journal  of 
Physiology,  Vol.  XXVII.  No.  V,  p.  427. 


DIABETES  281 

'  The  greatest  increase  in  heat  production,  which  was  brought 
about  by  the  cold  baths,  was  181  per  cent  above  the  normal. 
The  urine  remained  free  from  albumen  and  from  sugar. ' ' 

In  connection  with  the  oxidation  of  sugar,  it  is  interesting  to 
note  the  results  obtained  by  two  French  observers "  from  the 
inhalation  of  ozone  in  patients  suffering  from  glycosuria: — 

Labbe  and  Perochon  have  their  patients  with  glycosuria 
inhale  ozone  for  from  fifteen  to  thirty  minutes  a  day,  and 
have  found  that  in  some  way  it  promotes  the  utilization  of 
sugar,  so  that  sugar  disappears  more  or  less  completely  from 
the  urine.  Eight  typical  cases  are  described  to  show  the 
benefit  thus  realized.  In  one  case,  for  example,  a  man  of  57 
had  had  diabetes  for  six  years,  and  50  gm.  of  sugar  were  found 
in  the  liter  of  urine.  He  inhaled  ozone  for  fifteen  minutes  a 
day  for  two  months,  by  the  end  of  which  time  the  sugar  had 
vanished  from  his  urine.  Two  weeks  later  the  sugar  appeared 
anew  in  the  urine  and  ran  up  to  8  gm.,  but  subsided  to  traces 
on  resumption  of  the  ozone  treatment.  Another  patient  was  a 
woman  of  66  with  diabetes  for  many  years.  She  had  150  or  200 
gm.  of  sugar  to  the  liter  of  urine,  and  this  became  materially 
reduced  under  the  ozone  treatment  and  her  severe  pruritus  be- 
came very  much  improved."  12 

In  the  practical  application  of  hydrotherapy  the  treatment 
must  bs  carefully  graduated  and  mild  tonics  used  at  first, 
because  of  the  lowered  vitality  of  almost  all  diabetics.  Local 
hot  applications  followed  by  the  wet  hand  rub  or  cold  mitten 
friction  may  be  used  to  begin  with,  also  the  neutral  faradic  tub, 
graduated  shower,  and  cool  affusions.  After  becoming  accus- 
tomed to  these  treatments  the  patient  may,  if  in  good  flesh,  be 
given  a  wet  sheet  rub,  dripping  sheet  rub,  cold  shallow  bath, 
and  alternate  douches.  In  some  cases  the  cold  plunge  may 
even  be  ventured  upon.  As  rapidly  as  able,  the  patient  should 
be  encouraged  to  take  moderate  exercise  in  the  open  air;  the 
effect  is  greater  if  the  air  is  cold.  These  measures  improve  the 
appetite  and  stimulate  digestion  and  assimilation.  The  feeling 

11  Labbe  and  Perochon — Ozone  in   the  Treatment  of  Glycosuria,   Presse   Medicale, 
March  19,  XXI,  No.  23. 

12  Abstract  in  Journal  of  American  Medical  Association,  April  26,  1913. 


282  STIMULANTS  AND  TONICS 

of  languor  and  debility  gives  way  to  a  greater  inclination  to 
exercise,  and  so  hydrotherapy  indirectly  makes  possible  the  use 
of  the  other  great  aid  in  oxidation — bodily  activity. 

With  thin  diabetics,  the  prognosis  is  less  favorable.  They 
can  take  only  the  milder  tonic  treatments.  Neither  do  they 
bear  well  any  great  reduction  in  the  diet.  But  even  with  such 
unfavorable  conditions,  astonishingly  good  results  may  be 
obtained  by  carefully  graded  hydrotherapy  combined  with  light 
massage.  Much  time  should  be  spent  in  the  open  air  and  sun- 
shine, careful  attention  being  paid  to  general  hygiene  and 
especially  to  good  skin  activity. 

CEREBRAL  CONGESTION 
Due  to  the  Effects  of  Sunstroke  or  Heatstroke 

Patients  who  have  once  suffered  from  sunstroke  must  select  a 
cold  climate  in  which  to  live.  Even  moderate  heat  for  any 
length  of  time  produces  harmful  results.  It  would  seem  that 
in  this  condition  the  vasomotor  centers  have  been  so  interfered 
with  that  there  is  a  loss  of  vascular  control.  This  may,  in 
some  cases,  be  so  extreme  that  even  a  short  hot  treatment 
limited  to  a  small  area  may  induce  general  vaso-dilatation  with 
a  special  tendency  toward  cerebral  congestion.  The  condition 
is  best  treated  by  cold  applications  accompanied  by  friction. 
No  hot  applications  at  all  should  be  used.  During  all  treatment, 
the  head  should  be  kept  cool  by  cold  compresses  and  the  ice 
bag,  or  the  ice  cravat  to  the  neck.  The  cold  mitten  friction, 
cold  towel  rub,  wet  sheet  rub,  cool  or  cold  showers  and  sprays 
may  all  be  used  according  as  the  conditions  indicate.  If  the 
brain  seems  unduly  congested  a  great  deal  of  the  time,  deriva- 
tion is  best  secured  by  the  cold  percussion  douche  to  the  feet. 

Much  the  same  line  of  treatment  is  to  be  pursued  in  chronic 
•nitroglycerine  poisoning,  which  occasionally  occurs  in  miners. 
This  may  be  very  troublesome.  It  is  accompanied  by  severe 
headaches,  in  some  cases  assuming  a  migraine  type.  In  treat- 
ing these  patients,  the  cerebral  circulation  should  be  steadied 
by  bathing  the  head  in  cold  water  before  other  treatment  is  be- 
gun, which  latter  should  consist  of  cold  showers,  cold  percus- 


VALVULAR  HEART  DISEASE  283 

sion  douches,  and  the  cold  plunge.  If  milder  measures  must 
be  used,  the  cold  mitten  friction  with  ice  water  gives  excellent 
results.  However,  these  patients  bear  much  more  extreme 
cold  treatment  than  any  other  class,  and  seem  to  have  no  diffi- 
culty in  reacting. 

VALVULAR   HEART  DISEASE 
Etiology  and  Pathology 

Organic  heart  disease  refers  to  such  diseases  of  the  heart  as 
are  due  to  gross  structural  changes.  The  term  is  applied 
almost  exclusively  to  chronic  valvular  disease.  In  the  larger 
number  of  cases  this  is  the  result  of  some  acute  inflammatory 
condition  on  or  about  the  valves.  These  valve  inflammations 
may  arise  as  complications  of  rheumatic  fever,  tonsillitis, 
scarlet  fever,  sepsis,  gonorrhoea,  pneumonia,  pleurisy,  or 
pulmonary  tuberculosis.  Predispositions  are  found  in  pro- 
longed and  heavy  muscular  exercise,  auto-intoxication,  gout, 
alcoholism,  syphilis,  Bright's  disease,  and  arterio-sclerosis.  The 
result  is  a  valve  orifice  either  too  large  or  too  small.  Scar 
tissue  following  the  inflammation  may  cause  the  valve  segments 
to  adhere  to  each  other  and  so,  by  partially  obstructing  the 
orifice,  cause  stenosis;  the  valve  leaflets  may  be  partially  de- 
stroyed or  their  attachments  weakened  so  that  the  orifice  is 
too  large,  or  the  heart  dilated  so  that  the  segments  are  incom- 
petent to  close  the  opening. 

In  the  first  case,  that  is,  stenosis,  too  little  blood  passes 
through  the  orifice  and  extra  force  is  required  to  overcome  the 
obstruction.  In  the  latter  case,  part  of  the  blood  returns 
through  the  enlarged  opening  or  past  the  incompetent  valves, 
so  that  regurgitation  takes  place  at  every  heart  beat.  Because 
of  the  former  condition,  the  first  change  in  the  heart  muscle  is 
that  of  hypertrophy.  In  the  second  condition,  the  first  change 
is  that  of  dilatation  of  one  or  more  cardiac  chambers.  If  com- 
pensated, both  conditions  result  in  great  hypertrophy  and 
thickening  of  the  muscular  wall.  The  maximum  force  of  the 
heart  will  be  greater  than  normal,  but  the  work  required  of  it 
is  also  greater,  so  that  in  this  condition,  its  reserve  force  above 
what  it  ordinarily  uses  is  less  than  the  normal  reserve.  Here 


284  STIMULANTS  AND  TONICS 

the  heart  is  said  to  be  in  a  state  of  compensation,  since  the 
muscle  is  so  much  hypertrophied  as  to  still  be  able  to  perform 
its  work  under  ordinary  circumstances.  Sometimes  there  is 
little  or  no  such  reserve,  i.  e.,  the  heart  may  have  barely 
enough  force  for  its  work  when  the  body  is  at  rest.  In  this 


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Fig.  54.  Diagram  showing  dynamic  conditions  in  valvular  heart 
disease:  A— force  required  at  rest  under  conditions  indicated, 
B — additional  force  demanded  by  moderate  muscular  work"  C — 
reserve  cardiac  force  above  that  needed  for  moderate  work. 

condition,  the  heart  is  said  to  be  in  a  state  of  broken  compensa- 
tion. This  state,  that  is,  where  the  maximum  force  is  in  con- 
stant use,  is  revealed  by  such  symptoms  as  edema,  cyanosis, 
dyspnoea,  heart  pang  or  distress,  rapid  pulse,  palpitation,  sleep 
start,  enlarged  liver,  etc. 

Moderate  muscular  work  demands  four  times  the  energy  used 
at  rest,  and  the  total  reserve  power  of  the  heart  muscle  is  from 


VALVULAR  HEART  DISEASE  285 

eleven  to  thirteen  times  the  normal  output  during  rest.13  This 
proportion  is  shown  in  Fig.  54 1.  In  the  case  of  valvular  lesions 
so  bad  as  to  require  three  or  four  times  the  usual  expenditure 
of  energy,  it  will  be  seen  that  only  during  complete  physical 
rest  will  the  heart  be  able  to  accomplish  its  work  (Fig-.  54  //.). 
Moderate  muscular  exercise  will  demand  more  energy  than  it 
possesses,  and  so  will  be  accompanied  by  signs  of  broken  com- 
pensation. In  order  that  compensation  may  be  restored,  the 
muscular  wall  must  nearly  double  its  thickness  to  possess  even 
a  little  reserve  force,  as  shown  in  Fig.  54  III. 

Treatment 

It  will  be  readily  seen  that  the  above  conditions  set  forth  two 
indications  for  treatment:  First,  so  shaping  conditions  that  the 
heart  may  be  given  opportunity  to  increase  its  muscular  tissue 
and  thereby  its  reserve  force;  second,  as  much  as  possible,  re- 
lieve the  heart  of  part  of  its  work,  not  only  temporarily  in  order 
to  bring  about  the  condition  just  mentioned,  but  also  to  con- 
stantly assist  the  overtaxed  organ.  These  indications  are  met 
in  the  following  procedures: — 

1.  Rest — Physical  and  Mental.     This  is  first  and  foremost  in 
importance.      It  is   necessary .  that  absolute   physical    rest    be 
observed  in  the  state  of  broken  compensation.     Exercise  should 
not  be   permitted  until  the  heart  has  acquired  at  least  some 
reserve  force.     According  to  the  gravity  of  the  case,  physical 
rest  may  be  secured  by  absolute  quiet  in  bed,  by  rest  in  a  wheel 
chair  with  an   attendant,   or  by  restricted  exercise.     While  at 
rest  the  body  tissues  demand  less  oxygen,   and  consequently 
less  rapid  circulation.     It  is  quite  as  essential  to  eliminate  all 
nerve   strain,    such  as  worry,   apprehension,  business  or  social 
cares,  etc.      Through  the  avenue  of  the  sympathetic   system, 
these  irritate  and  overstimulate  the  intrinsic  nerves  of  the  heart 
muscle. 

2 .  The  Ice  Bag  to  the  Heart.      This  is  one  of  the  most  effi- 
cient means  we  possess  in  its  ability  to  produce  direct  tonic 
effects    upon   the    heart    muscle.      Prolonged,    continued    cold 
lessens  the  rate  and  increases  the  length  of  the  period  of  rest 

13    Hutchison  Applied  Physiology,  p.  116. 


286  STIMULANTS  AND  TONICS 

(diastole).  It  also  shortens  the  systole  and  increases  its  force. 
The  ice  bag-  should  be  well  wrapped  to  modify  the  intensity,  so 
that  the  application  may  be  prolonged.  In  some  cases,  the  cold 
compress  is  to  be  preferred.  While  the  ice  bag  tends  to  increase 
the  force  of  the  systole,  it  can  hardly  be  said  to  come  under  the 
head  of  pure  stimulants,  since  by  its  repeated  use,  the  effects 
of  over-stfmulation  are  never  seen.  It  always  exercises  a  bene- 
ficial effect  in  aiding  hypertrophy  of  the  heart  muscle,  since  by 
its  shortening  the  systole  and  increasing  the  length  of  the  dias- 
tole, the  actual  period  of  rest  is  increased.  It  may,  therefore, 
be  said  to  be  a  true  physiologic  measure. 

3.  Measures  which  Stimulate  the  Peripheral  Heart,  perform- 
ing part  of  the  work  of  the  circulation,  increasing  its  activity, 
and  so  aiding  the  central  heart.  In  the  chapter  on  the  peri- 
pheral heart,  we  have  discussed  at  length  the  physiology  of  the 
blood-vessels,  their  normal  action,  and  the  rationale  of  the 
measures  used  to  increase  this  activity. 

We  need  here  only  briefly  summarize  the  facts  already  pointed 
out.  Independently  of  the  heart,  the  blood-vessels  exert  a 
pumping  or  propulsive  action  upon  the  blood  stream. 

Lauder  Brunton  w  makes  the  following  observation  relative  to 
this  activity:  "  When  working  under  Professor  Ludwig  in  1869, 
he  directed  my  attention  to  the  contractile  power  of  the  small 
arteries  apart  from  any  nerve  center,  and  while  watching  their 
movements  I  have  sometimes  seen  a  regular  peristaltic  action 
take  place,  by  which  the  blood  was  driven  forward  in  the 
arteriole  just  as  faecal  matter  would  be  driven  forward  in  the 
intestine." 

Franke  discusses  the  various  theories  prevailing  in  regard 
to  the  functional  importance  of  the  peripheral  blood-vessels. 
His  conclusions  reaffirm,  he  asserts,' that  the  peripheral  vessels 
have  an  independent  pressure  and  suction  action  similar  to  that 
'of  the  heart.  This  assumption  is  sustained  by  their  anatomic 
structure,  physiologic  experiments,  direct  observation  of  the 
blood-vessels  in  living  animals,  and  in  certain  pathologic  con- 
ditions in  man.  At  the  points  where  there  is  the  greatest 
resistance  to  the  circulation,  Nature  has  placed  a  system  of 

14    Therapeutics  of  the  Circulation,  p.  5. 


VALVULAR  HEART  DISEASE  287 

especially  powerful  blood-vessels  like  a  second  peripheral  heart, 
as  in  the  portal  and  intestinal  vessels.  Compensation  may 
fail  from  disturbances  in  the  peripheral  vessels  as  well  as  in  the 
heart  itself,  and  the  peripheral  system  may  compensate  the 
heart  at  need;  the  vessels  in  the  abdomen  especially  are  the 
last  resort  of  all  means  to  maintain  the  balance  of  the  circula- 
tion. These  views,  he  considers,  explain  the  beneficial  effects 
of  gymnastics,  massage,  and  baths."  15 

In  disease,  as  long-  as  there  remains  any  vasomotor  control 
at  all ,  the  activity  of  the  blood-vessels  may  be  stimulated  by 
applications  to  the  skin  surface.  The  condition  of  the  blood- 
vessels to  be  sought  in  the  treatment  of  valvular  heart  disease 
is  that  known  as  active  dilatation,  not  only  of  the  arterioles, 
but  also  of  the  other  blood-vessels.  It  consists  of  an  alternate 
contraction  and  relaxation  occurring  at  regular  intervals.  It 
is,  in  short,  a  pumping  action.  It  is  often  astonishing  to  note 
the  amount  of  assistance  rendered  the  circulation  in  this  way, 
as  shown  by  prompt  decrease  in  the  pulse  rate  following,  or 
even  during,  some  of  the  procedures  listed  below.  These  may 
be  given  separately,  combined  in  one  treatment  or  at  different 
times  during  a  course  of  treatment,  as  indicated  by  conditions 
in  the  individual  case. 

(a)  Massage.  Friction  is  perhaps  the  mildest  of  measures  by 
which  the  peripheral  circulation  may  be  stimulated.  It  stimu- 
lates the  arterioles  and,  by  proper  movements,  the  venous  cir- 
culation is  hastened.  All  the  other  procedures  of  massage  are 
also  vasomotor  excitants. 

The  procedure  of  deep  kneading  accomplishes  more  than  the 
other  movements  of  massage.  It  acts  upon  the  circulation  in 
almost  the  same  manner  as  exercise.  The  alternate  compres- 
sion and  release  of  the  muscles  forces  on  their  contained  blood, 
so  that  the  rate  of  flow  is  greatly  accelerated.  Lauder  Brunton 
records  16  graphically  the  results  of  some  interesting  experiments 
showing  the  increase  in  the  rate  of  venous  outflow  from  muscles 
during  and  after  massage.  In  some  instances  the  rapidity  was 
increased  two  or  three  times  the  normal  rate. 

15  Abstract  in  Journal  of  American  Medical  Association   of  article  by  M.   Franke  in 
Wiener  klinische  Wochenschrift,  March  10,  1910,  XXIII,  No.  10,  p.  047. 

16  Therapeutics  of  the  Circulation,  p.  135. 


288  STIMULANTS  AND  TONICS 

Mechanical  vibration  is  quite  similar  in  its  effect  to  manual 
massage.  Vibration,  when  properly  given,  is  an  excellent 
means  of  assisting  the  peripheral  circulation,  especially  that  of 
the  feet  and  limbs.  Vibration  may  also  be  given  to  the  back 
and  other  parts,  as  indicated. 

(b)  Hydriatic  Vasomotor  Tonics.      The    cold    mitten  friction 
has  the  greatest  range  of  adaptability  in  organic  heart  disease. 
It  can  be  used  in  all  stages  from  the  inception  of  the  acute 
endocarditis  through  all  the  varying  conditions  of  established 
or  broken  compensation.     This  is  largely  due  to  the  readiness 
with  which  it  may  be  made  a  mild,  medium,  or  powerful  vaso- 
motor  tonic  and  stimulant.     This  can  be  accomplished  by  vary- 
ing the  temperature  of  the  water  used  and  altering  the  amount 
and    vigorousness    of    the    friction    given.      We    have    never 
observed,  even  after  the  most  vigorous  cold  mitten  friction,  or 
its  long  use  over  a  period  of  months,  any  overstimulation  such 
as  does  sometimes  occur  with  the  effervescent  bath.     The  cold 
mitten  friction  and  ice  bag  can  be  used  in  the  acute  stage  of 
endocardial  inflammation,  while  it  might  be  dangerous  to  use 
the  Nauheim  bath  in  this  stage.     There  are  many  other  hydri- 
atic   measures    similar    in   effect    to  the  cold   mitten  friction. 
Each  has  its  advantages   and   special   indications,   as  well  as 
limitations.     The  following  is  a  list  of  the  more  important  and 
commonly  used  hydriatic  measures  in  the  treatment  of  organic 
heart  disease:    The  salt  glow;  hot  and  cold  to  the  spine;  hot  and 
cold  douche  to  the  spine,  legs,   and  feet;   the  alternate  hot  and 
cold  foot  or  leg  bath.     Brief  fomentations  followed  by  a  brisk 
but  brief  cold  mitten  friction  may  be  given  to  any  part  of  the 
body  as  a  means  of  stimulating  the  peripheral  circulation. 

(c)  Nauheim    or  Effervescent   Bath.      The   essential    feature 
here   is  the  chemical  irritation  of  the   skin  produced   by   the 
carbon  dioxide  and  salines  with  which  the  water  is   charged. 
Natural  carbonated  waters  can  be  secured  in  only  a  few  locali- 
ties, but  the  carbonic  acid  gas  may  be  produced  artificially  in 
any  one  of  several  ways.     It  powerfully  stimulates  the  vaso- 
motors,    having,    however,    a   cumulative  action  on  the  vaso- 
dilators 17  so  that  the  heart  is  left  without  a  resistance  governor. 

17    Hare— Practical  Therapeutics. 


VALVULAR  HEART  DISEASE  289 

For  this  reason  it  is  necessary  to  discontinue  the  treatment  at 
intervals  in  order  to  obviate  palpitation  and  other  disturbing- 
symptoms.  The  cutaneous  irritation  also  reflexly  stimulates 
the  heart  (Hare).  This  may  be  another  factor  in  the  produc- 
tion of  palpitation  by  over-stimulation.  The  cooler  the  water 
the  less  likely  its  occurrence. 

When  the  patient  first  begins  to  take  the  Nauheim  bath,  it 
should  not  be  continued  longer  than  about  eight  minutes  at  a 
temperature  of  95°  F.  Five  minutes  may  be  better  in  some 
cases.  An  ice  bag  or  cold  coil  should  be  placed  over  the  heart. 
The  bath  may  be  repeated  two  or  three  times  a  week  for  from 
two  to  four  weeks.  It  is  usually  best  to  give  a  course  of  about 
twelve  treatments,  when  two  or  three  weeks  should  be  omitted. 
In  each  succeeding  treatment  the  temperature  of  the  water  may 
be  slightly  lowered  until  the  bath  is  taken  in  water  even  as  low 
as  80°.  The  duration  of  the  bath  may  be  increased  up  to 
twelve,  or  under  exceptional  circumstances,  fifteen  minutes. 
The  longer  the  duration  of  each  bath  and  the  more  frequent  its 
repetition,  the  greater  is  the  liability  to  over-stimulation.  This 
is  evidenced  by  palpitation,  tachycardia,  cyanosis,  and  dyspnoea. 

When  carefully  given,  the  Nauheim  bath  is  one  of  the  most 
useful  of  vasomotor  stimulants  and  tonics;  certainly  it  is  the 
most  powerful .  In  a  single  treatment  administered  to  a  patient 
with  a  dilated  heart,  the  area  of  cardiac  dullness  may  be  reduced 
in  diameter  by  as  much  as  three-quarters  of  an  inch  or  even  a 
little  over  an  inch.  These  results  are  not  occasional,  but  are 
the  general  rule.  The  ice  bag  is  very  useful  in  maintaining 
this  effect.  A  very  large  cardiac  liver  may  be  reduced  to 
normal  by  a  course  of  such  treatment  combined  with  other 
physiologic  vasomotor  tonics.  These  results  are  graphically 
shown  in  the  accompanying  physical  chart  (Fig.  55.).. 

(d)  Resistant  Gymnastics.  This  system  is  known  as  the 
Schott  treatment.  As  carried  out  by  the  Schott  Brothers,  it  is 
combined  with  the  Nauheim  bath.  It  consists  of  a  series  or 
system  of  graduated  exercises.  At  first  the  patient  is  assisted 
by  the  attendant;  later,  with  apparatus  or  alone.  First  one 
group  of  muscles  is  exercised  and  then  another,  until  the  prin- 
cipal muscle  groups  of  the  body  have  been  gone  over.  For 

19 


290  STIMULANTS  AND  TONICS 

example,  while  the  attendant  resists,  the  patient  gradually  con- 
tracts the  biceps,  flexing-  the  forearm.  When  the  forearm  has 
been  flexed,  the  patient  contracts  the  extensors  while  the 
attendant  resists  the  movement.  This  'is  gone  through  with  a 
number  of  times  for  each  group  of  muscles.  With  each  suc- 
ceeding- treatment  the  number  of  movements  and  the  strength 


Fig.  55.  A— border  of  cardiac  dullness  in  a  case  of  di- 
lated heart,  B — same  after  a  single  Nauheim  bath,  C — 
lower  edge  of  congested  (cardiac)  liver,  D — same  after 
a  course  of  tonic  hydrotherapy. 

of  the  resistance  is  increased.'8  The  gradual  contraction  and 
relaxation  of  first  one  and  then  another  group  of  muscles 
hastens  the  peripheral  circulation  and  tends  to  induce  the  state 
of  active  dilatation  of  the  blood-vessels.  This  treatment  should 
not  be  applied  in  acute  endocarditis,  but  is  applicable  in  the 
chronic  stage  where  compensation  is  not  seriously  broken. 

18    For  details  see  McKenzie— Exercise  in  Education  and  Medicine,  p.  328. 


VALVULAR  HEART  DISEASE  291 

O)  Oertel  Method.  General  exercises,  such  as  walking-,  use 
of  the  arms,  etc.,  follow  as  a  natural  consequence  of  the  method 
just  described.  As  a  system,  the  Oertel  method  consists  in 
graduated  climbing-  exercises,  up  hills  of  various  grades  and 
finally  even  mountain  climbing-.  At  first,  the  patient  walks  for 
short  distances  each  day;  and  later,  longer  distances  and  up 
steeper  grades.  This  is,  of  course,  applicable  only  where  a 
fair  degree  of  compensation  has  already  been  established;  never 
when  the  compensation  is  broken  or  in  the  slightest  impaired. 
Where  systematically  followed  for  months  or  years,  it  has 
resulted  in  much  good  and  will  secure  for  the  patient  the  maxi- 
mum cardiac  reserve. 

These  measures  combined  with  careful  diet  regulation,  fresh 
air,  and  sunshine  will  give  results  which  often  appear  like  a 
complete  cure,  but  of  course,  do  not  remove  the  defect  in  the 
heart.  At  the  beginning  of  the  incompetency,  the  progress 
may  be  stayed  for  years.  The  promptness  with  which  these 
measures  act  and  their  efficiency  has  to  be  seen  to  obtain  a  real 
appreciation  of  their  value.  For  example,  the  ice  bag  to  the 
heart,  accompanied  by  a  cold  mitten  friction,  may  reduce  the 
pulse  from  115  or  120  per  minute  to  100  or  less  within  fifteen 
or  twenty  minutes.  In  case  of  a  dilated  heart,  the  cardiac  dull- 
ness may  decrease  more  than  an  inch  in  diameter  and  the  apex 
retract  half  an  inch  or  more  toward  its  normal  position  follow- 
ing a  single  treatment.  In  case  the  valve  is  relatively  insuffi- 
cient, the  murmur  occasioned  by  this  insufficiency  may  entirely 
disappear,  whereas  before  treatment,  it  may  have  been  con- 
sidered to  constitute  a  real  organic  lesion.  The  minor  mur- 
murs of  the  valves  secondarily  affected  often  disappear  following 
a  treatment  of  fifteen  minutes  with  the  ice  bag  to  the  heart  and 
the  cold  mitten  friction,  or  ten  minutes  in  a  Nauheim  bath. 

Contraindications.  Extreme  stimulants  and  excitants  are 
contraindicated  in  organic  heart  disease,  unless  it  may  be  in 
emergency.  For  this  reason,  the  percussion  douche  to  the 
chest,  wet  sheet  rub,  the  cold  plunge,  and  such  measures  should 
not  be  used.  The  use  of  electricity  in  any  form  may  produce 
shock.  The  electric  light  bath  is  usually  contraindicated  or, 
if  used  at  all,  it  must  be  in  those  patients  which  have  acquired 


292  STIMULANTS  AND  TONICS 

a  good  degree  of  compensation,  and  then  only  for  a  short  time. 
All  other  extreme  sudorific  measures  are  contraindicated. 

General  Program 

We  have  already  outlined  under  the  head  of  endocarditis  the 
treatment  for  the  stage  of  acute  inflammation.  As  soon  as  the 
endocardial  inflammation  subsides,  the  patient  may  be  given 
daily  or  three  times  a  week  a  light  general  massage,  avoid- 
ing the  chest.  The  ice  bag  should  be  applied  to  the  heart  four 
or  five  different  times  during  the  day,  being  kept  in  place  from 
twenty  to  thirty  minutes  each  time.  Once  daily  the  patient 
should  have  a  treatment  consisting  of  a  combination  of  some  of 
the  following  measures:  Hot  foot  bath,  fomentations  to  the 
abdomen,  hot  and  cold  to  the  spine,  cold  mitten  friction,  and 
cold  towel  rub.  This  tonic  treatment  is  best  given  during  the 
forenoon.  The  massage  may  be  reserved  for  the  afternoon  or 
evening.  If  there  is  much  restlessness  or  insomnia,  it  may  be 
best  to  give  a  hot  and  cold  foot  bath  just  before  retiring.  Dur- 
ing this  time  the  patient  should  be  kept  in  bed;  but  when  the 
pulse  has  become  normal,  he  may  change  to  the  wheel  chair, 
and  later,  be  allowed  about  the  room,  walking  a  few  steps  or 
for  short  distances  only.  The  pulse  should  become  normal  be- 
fore any  regular  walking  exercises  are  taken.  The  patient  may 
now  be  given  a  salt  glow,  alternate  douche  to  the  feet  and  legs, 
graduated  shower,  etc.  The  Nauheim  bath  may  be  given  after 
the  temperature  has  been  normal  for  a  month  or  two.  This 
should  be  followed  by  the  Schott  treatment,  which  at  first 
should  last  only  a  few  minutes  and  consist  of  mild  exercises. 
Later  this  may  be  prolonged  and  increased  in  severity. 

In  case  the  patient  comes  under  observation  during  the 
chronic  stage,  with  compensation  broken,  the  treatment  maybe 
begun  at  this  point  or  perhaps  with  milder  measures.  The 
resistant  movements  should  not,  however,  be  used  during  the 
stage  of  broken  compensation.  Care  must  be  taken  that  the 
patient  is  not  treated  too  frequently.  This  may  often  seem 
necessary,  but  it  will  be  found  better  to  allow  the  patient  suffi- 
cient time  for  rest.  Three  treatments  a  day  are  usually  ample 
and  only  one  of  these  should  consist  of  the  more  vigorous 


VALVULAR  HEART  DISEASE  293 

stimulating-  measures.  The  evening  treatment  should  be  mild 
in  character,  sedative,  and  conducive  to  sleep.  The  afternoon 
treatment  may  be  the  hot  and  cold  foot  bath  followed  by  mas- 
sage. This  at  first  should  be  mild  and  not  last  more  than 
fifteen  or  twenty  minutes. 

Complications 

Edema.  The  edema  of  the  feet  and  legs  accompanying-  car- 
diac disease  will  improve  as  compensation  is  restored,  so  that 
all  of  the  measures  recommended  during  the  stag-e  of  broken 
compensation  will  aid  in  the  reducing  of  the  dropsy.  The  local 
measure  which  we  have  found  most  useful  is  the  alternate  hot 
and  cold  leg-  bath.  The  water  should  come  sufficiently  high  to 
more  than  cover  the  edematous  part.  The  limbs  should  be 
immersed  in  hot  water  for  one  and  a  half  to  two  minutes  and 
then  in  the  cold  for  ten  to  fifteen  seconds.  It  is  best  to  make 
the  hot  water  as  hot  as  can  be  borne,  gradually  adding-  more 
hot  water  as  the  toleration  increases.  The  cold  water  may,  at 
first,  be  used  at  a  temperature  of  50° — 70°  F.  Later,  chunks 
of  ice  should  be  put  into  the  receptacle  for  the  cold  water. 
From  five  to  ten  changes  may  be  made  at  one  treatment.  The 
limbs  should  be  dried  from  the  cold  water,  and  the  drying  fol- 
lowed by  massage  consisting  principally  of  centripetal  move- 
ments. The  limbs  should  be  kept  elevated  until  the  edema  has 
nearly  all  subsided. 

In  the  minor  grades  of  edema,  that  is,  where  there  is  swell- 
ing only  about  the  ankles,  vibration  may  be  applied  to  the  feet 
by  means  of  the  vibrating  foot  machine.  The  hot  and  cold  leg 
bath,  together  with  massage,  should  be  repeated  daily. 

Congestion  of  Liver.  The  liver  may  remain  congested  for 
some  time  after  the  heart  condition  has  materially  improved. 
Because  of  the  nature  of  the  hepatic  tissue,  the  organ  tends  to 
remain  enlarged.  The  passive  congestion  does  not  readily  re- 
spond to  treatment.  In  spite  of  these  facts,  an  enormously 
enlarged  liver  may  be  caused  to  return  to  nearly  normal  size  by 
a  month  or  two  of  vigorous  treatment.  The  patient  should  be 
given  large  fomentations  over  the  liver.  It  will  be  found  help- 
ful to  place  an  ice  bag  under  the  center  of  the  fomentation. 


294  STIMULANTS  AND  TONICS 

The  ice,  having-  a  greater  reflex  effect,  tends  to  contract  the 
blood-vessels  of  the  liver,  while  the  hot  application  shows  its 
effect  chiefly  in  derivation.  Alternating-  with  this  treatment, 
the  revulsive  compress  or  hot  and  cold  to  the  liver  should  be 
used.  The  alternate  douche  to  the  hepatic  region  is  one  of  the 
best  measures  that  can  be  used.  While  acting  somewhat  indi- 
rectly by  a  derivative  process,  the  hot  and  cold  leg  bath  will  be 
found  to  be  as  efficient  as  the  local  treatment. 

Acute  Edema  of  the  Lungs.  This  condition  may  come  on  be- 
cause of  chilling-  and  nervous  shock.  The  heart  becomes  en- 
gorged and  the  chambers  dilated  at  the  same  time.  The  patient 
should  be  immediately  wrapped  in  a  large  blanket,  the  feet  and 
legs  being  placed  in  hot  water  and  an  ice  bag  held  against  the 
precordia.  It  is  usually  necessary  for  the  patient  to  sit  up. 
The  ice  bag  may  be  removed  every  three  or  four  minutes,  the 
skin  being-  warmed  by  brisk  rubbing.  Another  attendant 
should  apply  to  the  spine  a  large  fomentation,  so  as  to  cover  its 
entire  length  and  breadth.  When  the  skin  is  well  redderfed,  a 
brief  but  very  cold  and  brisk  cold  mitten  friction  should  follow. 
Another  fomentation  should  be  applied  to  the  spine,  or  the 
part  may  be  dried  well  and  covered  with  the  blanket.  Each 
arm  and  leg  should  be  treated  in  a  similar  manner,  that  is,  the 
skin  well  warmed  and  reddened  by  a  fomentation  and  immedi- 
ately followed  by  a  cold  mitten  friction.  Each  part  should  be 
thoroughly  dried  with  a  rough  towel,  and  the  drying  followed 
by  friction  with  the  bare  hand  until  the  part  is  again  warm  and 
red.  The  object  to  be  obtained  in  this  treatment  is  the  drawing 
of  the  blood  from  the  heart  and  lungs  to  the  skin  and  skeletal 
muscles.  However,  this  can  not  be  effectually  done  by  hot 
alone,  but  must  be  accomplished  by  what  may  be  termed  "  col- 
lateral fluxion,"  that  is,  the  blood-vessels  of  the  surface  must 
be  stimulated  to  unusual  activity,  so  that  the  blood  will  be  held 
in  the  periphery.  This  not  only  acts  powerfully,  but  leaves  no 
bad  after  effects  such  as  are  frequently  noticed  when  these  com- 
plications are  treated  by  digitalis,  nitroglycerine,  and  strych- 
nine. Neither  are  these  latter  stimulants  able  to  accomplish 
the  desired  result  in  extreme  cases.  In  a  few  hours  the  moist 
rales  in  the  chest,  which  can  at  first  be  heard  at  some  distance, 


OBESITY  WITH  FA  TTY  HE  A  R  T  295 

will  have  entirely  disappeared.  The  finer  crepitant  rales  which 
remain  in  the  bases  of  the  lower  lobes  should  clear  up  in  from 
one  to  three  days. 

Palpitation  and  Arrhythmia.  These  conditions  are  largely 
due  to  digestive  disturbances,  especially  that  form  of  indiges- 
tion accompanied  by  gas  formation.  The  treatment  should, 
therefore,  be  directed  toward  the  relieving  of  constipation  and 
decreasing  of  amylaceous  dyspepsia.  It  may  be  necessary  to 
avoid  even  moderate  quantities  of  starchy  foods  unless  most 
thoroughly  dextrinized.  Tachycardia  is  best  controlled  by  the 
ice  bag,  cold  mitten  friction,  rest,  etc.  Nervous  disturbances, 
nerve  fatigue,  etc.,  are  also  responsible  for  temporary  arrhy- 
thmia. 

OBESITY  WITH  FATTY  HEART 

It  is  not  safe  to  employ  extreme  sweating  measures  in  obesity 
accompanied  by  fatty  degeneration  of  the  heart  muscle.  Con- 
sequently, the  treatment  of  these  cases  at  the  hot  springs  is  a 
dangerous  procedure.  They  must  be  treated  in  much  the  same 
manner  as  valvular  heart  disease.  The  patient  should  be  kept 
at  rest  with  an  ice  bag  over  the  heart  for  a  considerable  portion 
of  the  time.  Beside  this,  the  patient  should  be  given  cold 
mitten  frictions,  cold  towel  rubs,  hot  and  cold  to  the  spine, 
general  massage;  and  later,  the  alternate  douche  to  the  spine 
and  legs,  hot  and  cold  foot  bath,  wet  sheet  rub,  etc.  Treat- 
ment should  be  very  carefully  graduated  so  that  the  heart  is 
not  subjected  to  over-stimulation  before  it  has  sufficiently  in- 
creased its  strength. 

EXCITANT  AND  STIMULATING  EFFECTS 

In  many  emergencies  it  is  necessary  to  employ  extreme 
stimulating  measures.  These  aim  at  the  sustaining  of  vital 
activity  in  order  to  tide  the  system  over  a  crisis,  or  until  such 
time  as  the  natural  vitality  of  the  patient  comes  to  his  assist- 
ance. Such  measures  are  especially  directed  toward  the  heart, 
blood-vessels,  and  respiration.  In  collapse,  surgical  shock, 
drowning,  and  asphyxia,  these  measures  are  indicated.  As  we 
have  noted  many  times,  the  greatest  amount  of  assistance  to 


296  STIMULANTS  AND  TONICS 

'the  heart  can  be  given  by  vigorous  stimulation  of  the  peri- 
pheral blood-vessels.  In  addition  to  such  measures,  certain 
applications  may  be  used  which  have  a  direct  reflex  effect  upon 
the  heart  itself.  The  most  efficient  reflex  stimulation  comes 
through  the  accelerator  nerves.  Short  very  hot  fomentations 
may  be  applied  to  the  front  of  the  chest,  covering  well  the 
heart  area.  This  should  be  continued  from  thirty  seconds  to  a 
minute,  and  immediately  followed  by  the  rubbing  of  a  cake  of 
ice  over  the  heart.  The  extreme  change  in  temperature  pro- 
duces powerful  stimulation.  The  part  should  be  immediately 
dried,  after  which  a  second  fomentation,  very  hot  and  con- 
tinued for  half  a  minute  or  more  may  be  used,  again  followed 
by  the  ice  rub.  After  three  or  four  such  applications,  it  is 
well  to  rub  vigorously  with  the  bare  hand  the  skin  of  the  pre- 
cordia.  These  procedures  may  be  given  at  the  same  time  as 
artificial  respiration. 

A  very  efficient  stimulating  measure  is  the  slapping  of  the 
chest  with  a  cold  wet  towel.  If  this  is  done  during  the  move- 
ments of  artificial  respiration,  it  should  be  given  while  the 
inspiratory  movement  is  made.  In  the  asphyxia  of  the  new- 
born infant,  thermic  applications  are  indispensable.  If  slap- 
ping of  the  chest  and  buttocks  does  not  produce  respiration,  it 
is  well  to  employ  the  alternate  hot  and  cold  immersion.  Two 
large  dishpans  will  be  found  handy  containers  for  the  hot  water 
and  the  cold  water.  The  hot  water  must  not  be  hot  enough  to 
produce  a  burn  or  even  erythema.  It  must  be  of  such  a  tem- 
perature as  may  be  well  borne  on  the  back  of  the  hand  or  the 
cheek.  The  cold  water  should  produce  decided  excitation,  but 
ice  water  should  not  be  used.  The  child  should  be  held  in  the 
hot  water  for  ten  or  fifteen  seconds,  and  then  merely  dipped  in 
the  cold  water.  It  should  then  be  returned  to  the  hot  for  about 
the  same  length  of  time  and  again  dipped  in  the  cold.  Another 
plan  which  has  proven  equally  effective  is  rubbing  the  chest 
with  a  smooth  cake  of  ice  while  the  infant  lies  in  the  hot  water. 
These  procedures  are  usually  the  most  effective  stimulants  that 
can  be  used.  All  other  means  of  resuscitating  the  new-born 
have  their  place  and  applicability.  The  physician  should  not 
too  readily  become  discouraged  in  working  with  an  asphyxiated 


UTERINE  STIMULANTS  297 

infant.  It  may  require  half  or  three-quarters  of  an  hour  to  so 
stimulate  the  heart  and  respiration  that  the  child  will  continue 
to  breathe  without  artificial  means. 

Uterine  Stimulants 

Uterine  excitation  may  be  necessary  in  order  to  produce  two 
different  classes  of  effects,  viz.,  contraction  of  the  uterine 
muscle  and  prodiiction  or  increase  of  menstrual  flow. 

Oxytocic  Effects.  In  cases  of  inertia  uteri,  much  may  be 
accomplished  without  the  use  of  forceps.  That  vvhich  has  given 
us  the  best  results,  producing-  the  most  powerful  contractions, 
has  been  the  use  of  the  ice  bag-  or  cold  compress  to  the  lower 
abdomen,  applied  intermittently,  especially  just  at  the  begin- 
ning- of  the  pain,  or  short  intermittent  applications  of  cold  to 
the  breasts.  Alternate  hot  and  cold  applications  may  also  be 
made  to  the  lower  abdomen.  Both  areas  are  in  direct  reflex 
connection  with  the  uterus  and  produce  powerful  uterine  con- 
tractions. These  measures  are  less  disagreeable  to  the  patient 
than  manual  stimulation  through  the  abdominal  wall,  and,  on 
account  of  the  tenderness  often  produced  by  this  method,  are  to 
be  preferred  when  they  produce  the  desired  result. 

Emmen&gogic  Effects .  Wherever  amenorrhoea  is  due  to  pelvic 
anemia,  it  is  necessary  to  supplement  the  general  tonic  treat- 
ment by  special  stimulating-  treatments  directed  toward  the 
pelvic  org-ans.  This  may  be  accomplished  by  the  cold  percus-- 
sion  douche  to  the  lumbar  and  sacral  regions,  or  the  cold 
douche  to  the  lumbar  spine  and  feet.  Hot  vaginal  irrigation 
is  applicable  in  all  cases.  In  some  cases,  alternate  hot  and 
cold  vaginal  irrigation  may  be  used.  The  revulsive  sitz  is 
applicable  in  cases  of  extreme  pelvic  anemia.  It  may  be  fol- 
lowed by  the  cold  lumbar  and  sacral  douche.  This  douche 
should  be  accompanied  by  considerable  percussion  and  given 
for  only  a  short  time. 

Vesical  Stimulants 

Nearly  all  sudden  thermic  applications  to  the  feet,  leg's,  or 
trunk  produce  contractions  of  the  dedrusor  muscle.  This  is 
especially  true  of  the  cold  percussion  douche  to  the  feet,  or  the 


298  STIMULANTS  AND  TONICS 

alternate  hot  and  cold  douche  to  the  feet.  The  same  result 
may  be  accomplished  by  the  sudden  application  of  the  ice  com- 
press to  the  lower  abdomen  or  upper  inner  surfaces  of  the 
thighs. 

Intestinal  Stimulants 

Intestinal  excitation  is  indicated  chiefly  in  constipation. 
There  are  a  large  "number  of  measures  which  are  useful  in  re- 
laxed conditions  of  the  intestinal  musculature.  The  patient 
should  be  put  upon  some  regular  program.  This  may  con- 
veniently embody  several  of  the  measures  which  are  efficient  in 
stimulating  peristalsis.  Among  these  measures  are  the  hot 
enema,  cold  enema,  or  alternate  hot  and  cold  rectal  irrigation. 
The  graduated  enema  is  an  excellent  means  of  accustoming  the 
patient  to  the  cold  enema.  It  is  especially  useful  in  treating 
patients  who  have  acquired  the  enema  habit.  Of  external 
applications  there  may  be  employed  fomentations  to  the  abdo- 
men, the  revulsive  compress,  hot  and  cold  spray  doiiche  to  the 
abdomen.  These  same  measures  may  be  applied  to  the  spine 
from  the  middle  of  the  dorsal  region  to  the  sacral  region .  The 
alternate  hot  and  cold  percussion  douche  to  the  feet  and  legs 
also  tends  to  stimulate  peristalsis.  In  atonic  constipation  the 
cold  rubbing  sitz  is  an  excellent  measure.  It  should  last  from 
two  to  four  minutes  and  be  followed  by  the  alternate  douche  to 
the  spine  and  abdomen.  These  measures  should  be  carefully 
selected  and  utilized  according  to  the  severity  of  the  case, 
special  attention  being  given  to  the  cause.  The  above  treat- 
ments, except  the  hot  enema  and  fomentations  to  the  abdomen, 
are  not  applicable  in  spastic  constipation  such  as  that  accom- 
panying lead  poisoning.  In  this  case  it  is  best  to  use  fomenta- 
tions to  the  abdomen,  the  hot  sitz,  together  with  large  warm 
enemata  for  thorough  cleansing  of  the  colon  and  relief  of  the 
pain.  Oil  enemata  may  be  given  at  night  to  be  retained  over 
•night  or  for  several  hours. 

A  number  of  other  measures  not  hydriatic  in  nature  may  be 
conveniently  combined  with  hydrotherapeutic  treatment. 
Among  these  are  the  following:  Abdominal  massage,  spinal 
nerve  stimulation,  special  exercises  to  strengthen  the  abdominal 
muscles,  vibration  to  the  abdomen,  faradic  electricity  to  the 


CONTRAINDICATIONS  299 

abdomen  and  spine,  also  sinusoidal  electricity  and  the  Morton 
wave  from  the  static  machine.  Some  of  these  forms  of  electri- 
cal stimulation  may  be  applied  by  means  of  a  rectal  electrode 
and  an  abdominal  sponge.  All  exercises  which  strengthen  the 
abdominal  muscles  should  be  utilized,  such  as  walking-,  rowing, 
horseback  riding,  bicycling,  etc. 

Contraindications  to  Excitant  and  Stimulating  Measures. 

1.  Old  age. 

2.  Infancy. 

3.  Arterio-sclerosis. 

4.  Acute  mania. 

5.  Tuberculosis  (pulmonary). 

6.  Emaciation. 

7.  Thin  diabetic  patients. 

8.  Bright' s  disease. 

9.  Exhaustion  from  any  cause. 

10.  Hemorrhage. 

11.  Severe  coughing. 

12.  Asthma. 

13.  Emphysema. 

14.  Organic  heart  trouble. 

15.  Chorea. 

16.  Extreme  neurasthenia. 


CHAPTER  XXI 
SEDATIVE  EFFECTS 

MEASURES  which  reduce  or  check  the  over-activity  of  an 
organ  or  function  are  said  to  have  a  sedative  effect. 
Since  there  are  many  organs  and  functions,  one  might  so  elab- 
orately classify  sedative  effects  as  to  prove  confusing,  and  so 
lose  the  distinctive  principles  governing  hydriatic  sedatives. 
Any  application  must  of  necessity  affect  more  than  one  struc- 
ture, as  we  have  learned  concerning  tonic  measures;  but  we 
have  also  learned  that  every  application  has  its  predominating 
effect.  For  the  sake  of  clearness  we  shall,  therefore,  here  dis- 
cuss only  nerve  sedatives — those  measures  which  relieve  irrita- 
tion, nervousness,  spasm  and  convulsions,  and  are  conducive  to 
rest,  relaxation,  or  sleep.  The  principal  sedative  measures 
may  be  classified  as  follows: — 

I.  GENERAL  SEDATIVES. 

1.  Pure  sedatives. 

2.  Tonic  sedatives. 

II.  LOCAL  SEDATIVES. 

1.  For  the  relief  of  pain  (analgesics). 

2.  For  the  relief  of  paraesthesia. 

The  first  (I)  employs  mild  hypnotic,  calmative,  and  anti- 
spasmodic  means,  and  mild  tonics  almost  entirely.  The  second 
•(II)  must,  of  necessity,  employ  extreme  means,  since  pain  and 
abnormal  sensations  can  not  be  relieved  by  mild  applications. 

GENERAL  SEDATIVES 

1.  Pure  Sedatives:  Temperatures  at  or  not  far  removed  from 
neutral. 

(300) 


GENERAL  SEDATIVES  301 

(a)  Neutral  or  warm  bath  94° — 98°  F. 

(b)  Neutral  wet  sheet  pack. 

(c)  Continuous  flowing-  bath. 

(d)  Oxygen  bath. 

.   (e)  Warm  or  hot  shower,  spray,  douche,  or  affusion. 

(f)  Neutral  pour  to  spine. 

(g)  Sponging- — cool,  tepid,  or  warm. 

(h)  Heating  compress,  as  moist  abdominal  girdle,  spinal  com- 
press, throat  compress,  moist  chest  pack,  etc. 

(i)  Fomentations  moderately  hot,  especially  to  spine  and 
abdomen. 

In  addition  to  the  above,  the  following  sedatives  are  espe- 
cially directed  toward  decreasing  the  congestion  of  nerve 
centers. 

(a)  Hot  foot  bath  with  cold  to  the  head. 

(b)  Cold  sitz  bath. 

(c)  Cold  water  coil  to  abdomen  or  head. 

(d)  Alternate  hot  and  cold  percussion  douche  to  feet. 

It  will  be  noticed  that  all  of  these  measures,  unless  it  be  the 
neutral  bath,  secure  sedation  by  combining  the  purely  sedative 
effects  with  that  of  derivation.  For  example,  the  hot  foot  bath 
with  cold  to  the  head  produces  sleep  and  relieves  nervousness 
and  headache  by  reducing  cerebral  congestion. 

The  wet  sheet  pack  at  65° — 70°  F.,  given  alone  or  followed 
by  a  graduated  shower  at  95° — 90°  F.,  is  effective  because  of 
the  relief  of  cerebral  hyperemia  which  it  produces,  combined 
with  pure  sedation.  Relative  to  the  effects  of  the  cold  wet 
pack,  Baruch  l  says: — 

The  experiments  of  Max  Schiiller  and  the  observations  of 
Mary  Putnam  Jacobi  have  so  clearly  demonstrated  the  calming 
influence  of  the  wet  pack  upon  the  cerebral  circulation  that  we 
have  an  exact  basis  upon  which  this  treatment  may  be  applied 
in  many  cases  of  neurasthenia,  especially  those  tixrablesome 
cases  in  which  insomnia  is  a  pronounced  manifestation. 

'  This  procedure  is  one  of  the  most  effective  means  of  quiet- 
ing the  entire  nervous  system,  whether  the  irritable  condition 
be  due  to  an  essential  increase  of  reflex  excitability  or  to  a  cere- 

1    Principles  and  Practice  of  Hydrotherapy,  p.  440. 


S02  SEDATIVE  EFFECTS 

bral  hyperemia.  The  pronounced  sinking  of  the  brain  sub- 
stance, the  positive  diminution  of  the  respiration  and  heart  beat, 
the  weakening  of  the  reflex  excitability  and  of  activity  of  the 
cerebral  ganglia  observed  in  trephined  rabbits  during  the  wet 
pack,  combined  with  the  positive  diminution  of  the  vessels  of 
the  pia  mater,  represent  the  fundamental  conditions  for  physi- 
cal calm  and  sleep.  These  are  probably  also  present  in  man 
during  the  wet  pack.  Sleep  is  accompanied  by  a  decided  dim- 
inution of  blood  in  the  cerebral  vessels;  indeed,  the  latter  has 
been  accepted  as  an  essential  condition  for  the  production  of 
sleep.  This  may  explain  why  the  wet  pack,  properly  applied, 
is  a  useful  procedure  in  the  insomnia  of  neurasthenics." 

The  cold  sitz,  cold  coil  to  the  abdomen,  etc.,  produce  sedation 
by  reducing  congestion  of  the  sympathetic  ganglia  of  the  abdo- 
men and  pelvis.  Fomentations  to  the  spine  withdraw  blood 
from  the  spinal  cord,  and  the  heat  is  in  itself  relaxing  and  de- 
pressant. Heating  compresses  are  mild  derivatives  and  com- 
bine with  this  derivation  a  neutral  temperature.  All  antipy- 
retic measures  are  in  the  nature  of  the  case  antispasmodic  and 
hypnotic,  since  they  lessen  toxemia  and  so  relieve  the  nervous 
system.  Cold  sponging  is  sedative  in  both  actual  fever  and 
feverishness.  Hot  sponging  is  usually  most  effective  in  condi- 
tions purely  nervous.  In  acute  mania  the  wet  sheet  pack  is  a 
most  excellent  means,  and  serves  a  double  purpose  in  restrain- 
ing the  patient  while  applying  the  neutral  temperature. 

Indications  for  the  Use  of  Pure  Sedatives. 

1.  Insomnia. 

2.  Agitative  neurasthenia. 

3.  Hysteria. 

4.  Mania. 

5.  Chorea  and  choreiform  diseases. 

6.  Paralysis  agitans. 

7.  Spastic  spinal  paralyses. 

8.  Epilepsy. 

9.  Locomotor  ataxia  (first  stage). 

10.  Nervousness  due  to  congestive  headache. 

11.  Clonic  and  tetanic  spasms  from  various  causes. 


TONIC  SEDATIVES  303 

Precautions.  The  personal  factor  or  idiosyncrasy  has  much 
to  do  with  the  selection  of  a  sedative  treatment.  If  a  patient 
has  taken  a  dislike  to  a  certain  measure,  it  is  likely  to  produce 
agitation  rather  than  sedation.  Sedative  effects  are  likely  to 
be  transient,  and  so  the  treatment  must  be  frequently  repeated. 
With  neurasthenic  patients  a  treatment  which  may  have  given 
good  results  in  a  certain  case  may  be  robbed  of  its  effect  by 
some  unusual  occurrence  which  may  seem  trivial  in  itself,  such 
as  slight  alteration  in  the  manner  in  which  it  is  given,  or  the 
changing  of  an  attendant. 

2.  Tonic  Sedatives.  Insomnia  and  nervousness  may  be  due 
to  a  lack  of  normal  fatigue  such  as  follows  active  work,  espe- 
cially out  of  doors.  This  is  particularly  true  of  those  in  seden- 
tary occupations,  such  as  professional,  business,  and  office  men. 
These  persons  may  be  of  fairly  good  physique  and  health  other- 
wise. It  also  occurs  in  enforced  idleness,  as  after  fractures, 
operations,  etc.,  and  in  the  case  of  chronic  invalids.  The 
rational  treatment  consists  in  the  production  of  fatigiie.  Where 
possible,  of  course,  exercise  in  the  open  air  is  the  most  efficient 
means  of  producing  fatigue.  Mild  tonics  are  usually  all  that 
can  be  well  borne.  A  few  cases  may  be  given  even  the  most 
vigorous  treatment.  The  following  are  the  means  most  used 
as  tonic  sedatives: — 

(a)  Hot  and  cold  to  the  spine. 

(b)  Wet  hand  rub. 

(c)  Cold  mitten  friction. 

(d)  Hot  and  cold  spray,  shower,  or  douche. 

(e)  Neutral  faradic  tub. 

(f)  Massage. 

(g)  Rapid  faradic  current. 

The  indications  have  been  outlined  above.  Some  of  the  prin- 
cipal conditions  requiring  tonic  measures  in  order  to  produce 
sedation  are, — 

1.  Insomnia. 

2.  Neurasthenia. 

3.  Splanchnic  neurasthenia. 

4.  Chronic  rheumatism. 

5.  Paralyses  (flaccid). 


304  SEDATIVE  EFFECTS 

LOCAL  SEDATIVES 

1.  Analgesics  (relief  of  pain).  For  the  purpose  of  relieving 
pain,  extreme  hot  or  cold  applications  are  absolutely  essential. 
Just  which  shall  be  used  depends  upon  the  particular  cause  and 
condition  in  each  case.  Some  aim  at  the  cause  and  others  at 
the  immediate  relief  of  the  pain,  where  the  cause  can  not  be 
removed  in  a  short  time. 

For  the  relief  of  pain,  hot  applications  are  usually  employed. 
We  say  that  heat  has  a  specific  pain-relieving  effect.  This  is 
true;  but  it  must  be  remembered  that  the  relief  of  the  pain  is 
due  to  the  production  of  definite  circulatory  changes  which  re- 
move the  cause  of  pain.  In  inflammatory  states  the  cause  of 


Fig.  56.    Diagram  to  show  the  effects  of  heat  and  cold  in  lessen- 
ing the  pain  of  inflammation.    ( Brunton.) 

pain  is  to  be  found  in  pressure  upon  nerve  filaments  occasioned 
by  the  congestion  and  heightened  vascular  tension.  By  deriva- 
tion, heat  reduces  the  congestion  or  it  relaxes  the  tension,  and 
thus  the  cause  of  pain  is  removed.  When  properly  applied, 
cold  may  accomplish  the  same  results.  These  principles  are 
well  illustrated  in  a  diagram  devised  by  Lauder  Brunton.2 

'  The  diagram  (Fig.  56.)  is  supposed  to  represent  the  end  of 
the  finger.  The  small  star  indicates  the  point  of  irritation, 
e.g.,  a  prick  by  a  thorn.  The  line  in  the  center  of  each  finger 
is  intended  to  represent  the  nerve  going  to  the  injured  part; 
and  at  the  side  of  each  figure  is  an  artery  and  vein  connected 
by  a  capillary  network.  In  a  the  capillary  network  around  the 

2    Therapeutics  of  the  Circulation,  p.  174. 


ANALGESICS  305 

seat  of  irritation  is  seen  to  be  much  congested;  the  nerve  fila- 
ments are  thus  pressed  upon,  and  pain  is  occasioned.  B  repre- 
sents the  condition  of  the  finger  after  the  application  of  cold  to 
the  arm  or  hand.  In  consequence  of  the  contraction  of  the 
afferent  arteries,  the  finger  becomes  anemic;  no  pressure  is  ex- 
erted on  the  nervous  filaments,  and  pain  is  alleviated.  C  repre- 
sents the  finger  after  it  has  been  encased  in  a  warm  poultice; 
the  capillary  network  at  the  surface  of  the  finger  is  dilated,  and 
the  blood  is  thus  drawn  away  from  the  seat  of  irritation,  and 
the  pain  therefore  relieved." 

For  the  relief  of  pain  the  following  treatments  are  useful: — 

(a)  Very  hot  fomentations. 

(b)  Hot  immersion,  foot  bath,  sitz,  etc. 

(c)  Hot  pack,  local  or  full  blanket  pack. 

(d)  Hot  enema. 

(e)  Extreme  cold,  as  ice  bag,  ice  compress  to  painful  part 
or  over  artery  supplying  the  part,  use  of  ice  water  or  cracked 
ice  by  mouth. 

(f)  Cold  immersion,  as  of  a  hand  or  foot,  sitz  bath,  etc. 

(g)  Derivation. 

(h)  Fluxion  by  alternate  extreme  hot  and  cold  applications. 
The  indications  for  the  use  of  pain-relieving  measures  are 
numerous. 

Pain  of  deep-seated  inflammation. 

Pain  of  superficial  inflammation. 

Gastric  ulcer. 

Rectal  ulcer. 

Hemorrhoids. 

Toxic  neuralgia. 

Inflammatory  neuralgia. 

Tenesmus — rectal  or  vesical. 

Dysmenorrhea. 

Colic — renal,  biliary,  intestinal. 

Burns. 

Sprains,  bruises,  etc. 

Fractures. 

2.  Relief  of  Paresthesias  (abnormal  sensations,  such  as  burn- 
ing, smarting,  itching,  crawling  sensations). 
20 


S06  SEDATIVE  EFFECTS 

(a)  Ice  bag". 

(b)  Immersion  in  cold  water  or  ice  water. 

(c)  Very  hot  sponging:. 

(d)  Stupes. 

(e)  Weak  chemical  irritants,  as  neutral   saline  bath,  bicar- 
bonate of  soda  bath,  saline  sponging,  alcohol  rub,  witch-hazel 
rub,  menthol  compress. 

(f)  Short  sweating  bath  followed  by  tub  shampoo  and  cool 
bath. 

Indications: — 

1.  Pruritis  from  various  causes.- 

2.  Hives  and  heat  rashes. 

3.  Formication. 

4.  Numbness  and  tingling1. 

5.  Burning  and  smarting. 

INSOMNIA 

Baruch  not  inaptly  styles  the  insomnia  of  neurasthenia  an 
opprobrium  medicorum.  If  one  were  to  form  an  opinion  from 
the  bad  effects  of  medicinal  treatment  and  the  frequency  with 
which  such  treatment  is  used,  the  condition  is  indeed  a  dis- 
credit to  scientific  medical  practice.  The  insomnia  accompany- 
ing' neurasthenia  is  due  to  a  peculiar  association  of  nerve 
exhaustion  with  hyperirritability.  Doubtless  nerve  poisons 
from  auto-intoxication  play  a  large  part  in. the  causation.  It 
would  seem  that  congestion  of  the  cerebral  and  spinal  centers 
is  also  a  cause  of  nerve  irritability  and  sleeplessness.  It  is 
present  in  the  majority  of  cases. 

Because  of  the  lack  of  nerve  tone,  general  tonic  treatment,  as 
outlined  for  neurasthenia,  is  quite  as  essential  as  sedative 
measures  which  aim  principally  at  the  insomnia.  In  many 
patients,  lack  of  normal  fatigue  is  the  chief,  if  not  the  sole 
cause.  In  such  cases  a  mild  or  even  a  vigorous  tonic  treat- 
ment given  about  an  hour  before  bedtime  will  produce  the  best 
results.  With  some  persons  brisk  exercise  to  the  point  of 
moderate  fatigue,  taken  just  before  retiring,  will  accomplish 
the  same  results. 

We  have  principally  to  consider  the  insomnia  due  to  increased 


INSOMNIA  307 

reflex  excitability  and  unusual  irritability  of  the  nerve  centers. 
The  condition  may  be  perpetuated  long-  after  removal  of  the 
first  cause  has  been  effected.  This  is  especially  true  of  those 
patients  who  "  can't  go  to  sleep  "  because  of  constant  worrying 
about  their  inability  to  sleep.  These  persons  are  the  bane  of 
the  neurologist's  life.  They  are  exceedingly  introspective  and 
often  almost  hysterical.  In  order  to  decrease  reflex  excitability 
it  is  necessary  to  remove  as  far  as  possible  all  external  stimuli 
and  at  the  same  time  decongest  the  spinal  and  cerebral  centers. 

For  these  purposes  the  ideal  means  is  found  in  the  neutral 
bath  or  pack.  The  body  is  enveloped  in  a  non-irritating 
medium,  the  skin  is  slightly  warmed  and  both  the  skin  and 
the  skeletal  muscles  relaxed.  The  temperature  of  the  neutral 
bath  should  be  not  less  than  94°  F.  and  it  is  often  better  to  use 
water  a  little  warmer,  say  96°  or  97°  F.,  since  the  warmth 
secures  a  full  relaxation.  The  bath  should  be  given  in  a  quiet, 
fairly  warm  room  and  last  for  fifteen  or  twenty  minutes  to  a 
half  hour  or  longer.  The  disturbing  effect  of  drafts  may  be 
avoided  by  stretching-  a  sheet  across  the  top  of  the  tub.  It  is 
well  to  lower  the  temperature  of  the  water  two  or  three  degrees 
just  at  the  close  of  the  bath.  A  patient  should  never  be  put 
into  a  neutral  bath  with  cold  feet.  All  parts  of  the  body  should 
be  warm  beforehand.  The  neutral  bath  or  warm  bath  has  an 
effect  similar  to  the  neutral  pack  in  causing  the  sinking  of  the 
brain  substance.  The  rationale  of  the  wet  sheet  pack  has 
already  been  explained.  With  many  patients  it  is  the  most 
efficient  means  that  can  be  used.  By  means  of  woolen  blankets 
the  covering  of  the  pack  can,  by  an  observant  nurse,  be  so 
regulated  as  to  be  kept  constantly  at  the  neutral  stage.  The 
feet  should  be  more  warmly  covered  than  the  upper  part  of  the 
body.  An  exceedingly  restless  patient  who  has  had  but  little 
sleep  for  weeks  may  sleep  for  hours  or  all  night  in  a  neutral 
pack. 

For  cases  of  agitative  neurasthenia  with  insomnia  we  have 
recently  found  the  oxygen  bath  more  efficient  than  any  other 
means.  The  temperature  of  the  water  should  be  97°  or  98°  F. 
since  the  oxygen  g-as  produces  a  slight  anemia  of  the  skin.  For 
the  same  reason  it  is  well  to  precede  the  bath  by  a  hot  foot 


308  SEDATIVE  EFFECTS 

bath  or  fomentations  to  the  spine.  The  bath  itself  lasts  twenty 
minutes.  No  pour  or  shower  or  any  other  stimulating-  measure 
should  be  used  after  it.  The  bath  should  be  taken  in  the  late 
afternoon  or  early  evening-,  never  later  than  7:30  p.  M.  It  may 
be  used  daily,  but  it  seems  to  give  as  good  or  better  results 
administered  three  times  a  week  only.  The  method  and  other 
effects  are  described  under  technique  (q.  v.). 

The  salutary  effects  of  a  drug-less  sleep  are  felt  all  the  next 
day.  There  is  not  the  usual  after-tendency  to  drowsiness. 
The  patient  feels  like  himself.  Quite  the  contrary  condition 
follows  the  rest  obtained  by  trional,  the  bromides  and  other 
hypnotics.  The  patient  is  likely  to  be  drowsy  during-  the  suc- 
ceeding- forenoon.  For  this  reason  medicinal  soporifics'  often 
defeat  their  own  end.  The  patient  must  be  kept  awake  during 
the  daytime  so  that  natural  fatig-ue  may  result  and  thus  the 
system  demand  rest  and  sleep. 

There  are  many  other  measures  which  will  be  found  useful. 
The  milder  types  of  insomnia  respond  very  quickly  to  a  set  of 
three  fomentations  to  the  spine  given  just  at  bedtime.  If 
thought  best,  this  may  be  followed  by  a  light  rub  either  to  the 
spine  alone  or  to  the  body  generally.  The  tepid  spinal  affusion 
has  an  effect  similar  to  the  spinal  fomentation.  It  should  be 
applied  to  the  lower  dorsal  and  lumbar  spine.  Some  cases  of 
insomnia  seem  to  be  due  solely  to  cerebral  hyperemia.  This  is 
common  in  brain  workers.  In  these  cases  the  feet  are  almost 
invariably  cold.  If  the  unbalance  is  extreme,  a  very  hot  foot 
or  leg  bath  with  cold  to  the  head  should  be  given  for  about  ten 
or  fifteen  minutes.  This  should  be  followed  by  an  alternate 
hot  and  cold  percussion  douche  to  the  feet.  Sometimes  the 
latter  will  accomplish  the  results  as  well  when  given  alone  as 
following  the  hot  foot  bath.  The  vigorous  fluxion  produced  in 
the  feet  by  the  combination  of  percussion  with  thermic  stimuli 
•  results  in  more  permanent  cerebral  derivation  than  a  hot  foot 
bath  alone. 

The  moist  abdominal  girdle  is  an  excellent  adjunct  to  a 
sedative  treatment.  As  shown  by  the  experiments  of  Schiiller, 
it  lessens  the  filling  of  the  cerebral  vessels.  It  may  be  used 
after  any  of  the  treatments  recommended  above.  It  shoulcl.be 


CHOREA  309 

worn  all  night.  If  properly  applied,  it  will  be  dry  or  nearly  dry 
by  morning-.  If,  because  it  does  not  promptly  "warm  up," 
chilliness  results,  it  must  be  removed.  With  some  patients  it 
produces  "  fidgets  "  and  for  this  reason  must  be  discontinued. 
Of  tonic  sedatives  designed  to  aid  in  producing  normal 
fatigue,  the  following-  may  be  used  in  insomnia:  Hot  and  cold 
to  the  spine,  the  cold  mitten  friction,  the  alternate  spray  or  a 
short  electric  light  bath  followed  by  a  spray.  The  neutral 
faradic  tub  followed  by  a  short  massage  gives  good  results. 
Either  one  may  be  used  alone.  The  mild  exercise  occasioned 
by  dry  faradism  or  the  faradic  tub  is  often  sufficient  to  induce 
sleep.  In  the  management  of  most  cases  of  neurasthenic 
insomnia,  it  is  best  to  give  a  tonic  treatment  in  the  forenoon, 
reserving  sedative  treatment  and  massage  for  the  afternoon 
or  evening.  Following  the  plans  outlined  above,  or  similar 
methods,  carefully  adapting  the  treatment  to  the  needs  of  the 
particular  case  under  observation,  can  not  fail  to  produce  cure 
provided  the  patient  fully  commits  himself  to  the  judgment  of 
the  physician  and  remains  long  enough  to  secure  permanent 
results. 

CHOREA 

The  common  or  Sydenham's  chorea  is  the  form  especially 
considered  here.  This  is  the  type  which  is  associated  with 
rheumatic  fever  and  endocarditis,  occurring  from  five  to 
twenty-five  years  of  age  and  most  frequent  between  the  ages  of 
five  and  fifteen.  It  may  also  occur  during  pregnancy.  The 
cause  is  not  definitely  known.  The  chorea  movements  are 
sharp,  decisive,  and  irregular.  Huntington's  chorea  is  also 
benefited  by  the  methods  outlined  below. 

The  condition  demands  a  period  of  absolute  rest  in  bed  with 
freedom  from  all  excitement.  Chorea  can  best  be  treated  in  an 
institution  away  from  friends  and  relatives.  All  possible  sources 
of  auto-intoxication,  such  as  bad  diet  and  constipation  should 
receive  special  attention.  The  hydriatic  management,  while 
very  simple,  is  of  great  importance.  During  the  period  when 
perfect  rest  is  demanded,  pure  sedatives  should  be  used.  Of 
these  the  neutral  bath  is  most  efficient.  It  should  be  given 


S10  SEDATIVE  EFFECTS 

once  or  twice  a  day  and  prolonged  from  twenty  minutes  to  an 
hour.  The  bath  should  feel  warm,  having  a  temperature  of 
96°  or  97°  F.  On  the  alternate  days  the  oxygen  bath  may  be 
substituted  with  good  results.  The  wet  sheet  pack  may  also 
be  used,  being  kept  at  the  neutral  stage.  It  should  last  about 
the  sams  length  of  time  as  the  bath,  or  the  patient  may  be 
allowed  to  sleep  in  it  and  be  removed  later  with  a  wet  hand  rub. 
After  some  improvement  has  been  secured,  in  a  week  or  ten 
days,  other  sedative  means  which  combine  with  them  mild 
tonic  effects  may  be  used.  These  should  at  first  be  very  mild, 
such  as  a  wet  hand  rub,  tepid  sponging,  and  the  neutral  spinal 
affusion  or  pour.  The  heating  abdominal  compress  or  moist 
abdominal  bandage  may  give  good  results.  Fomentations  to 
the  spine,  followed  by  the  cold  heating  compress  for  fifteen  to 
twenty  minutes  is  an  excellent  sedative.  During  the  entire 
course  of  treatment,  the  neutral  baths  or  packs  should  be  con- 
tinued. When  convalescence  is  well  established  the  cold  mitten 
friction,  cold  towel  rub,  graduated  and  alternate  sprays  may  be 
used,  also  light  massage.  All  of  these  measures  serve  to 
remedy  the  anemia;  even  the  neutral  bath  is  helpful  in  this 
direction.  The  beneficial  effects  of  outdoor  life  in  the  country, 
sunshine  and  fresh  air  can  not  be  over-estimated. 

In  case  chorea  is  complicated  by  endocarditis,  the  same 
system  of  treatment  should  be  followed  as  outlined  for  the  en- 
docarditis of  rheumatism.  The  only  alteration  necessary  is  the 
substitution  of  sedative  treatment  once  or  more  daily  for  some 
of  the  tonic  treatment,  such  as  the  cold  mitten  friction  used  in 
rheumatic  endocarditis. 

PARALYSIS  AGITANS 

While  this  is  considered  an  incurable  affection,  the  patient 
may  be  much  benefited  and  the  progress  of  the  disease  stayed 
for  quite  long  periods  of  time  by  general  h)'gienic  management 
combined  with  sedative  and  mild  tonic  hydrotherapy.  The 
measures  recommended  above  for  chorea  are  all  helpful  in 
shaking  palsy.  Dana3  especially  recommends  the  lukewarm 
(neutral)  bath  and  mild  massage.  Oppenheim4  has  seen 

3  Text  Book  of  Nervous  Diseases. 

4  Diseases  of  the  Nervous  System. 


SPASTIC  PARALYSES  311 

improvement  following-  the  use  of  the  faradic  bath.  Vibrating 
chairs  or  vibrating-  machines  adjusted  to  give  a  fine  rapid  move- 
ment may  show  good  results.  Outdoor  life  in  the  woods  and 
country  are  especially  beneficial. 

SPASTIC  SPINAL  PARALYSES 

There  are  a  number  of  lesions  of  the  cord  which  ultimately 
result  in  degeneration  of  the  upper  motor  neuron,  chiefly  in  the 
lateral  column.  The  inhibitory  control  from  the  cerebral  cortex 
being  cut  off,  a  condition  of  spastic  paralysis  results,  i.  e.,  a 
loss  of  control  associated  with  rigidity  and  spasticity  of  the 
muscles.  Such  a  condition  occurs  after  various  forms  of 
myelitis,  especially  a  transverse  myelitis,  also  in  amyotrophic 
lateral  sclerosis.  If  there  is  an  acute  onset  as  by  trauma  or  in- 
flammation, as  frequently  occurs  in  myelitis,  the  patient  must 
be  put  to  rest,  either  absolute  or  partial,  according  to  the 
nature  and  needs  of  the  case.  In  some  cases  gentle  spinal  ex- 
tension should  be  used  for  some  weeks  and  perfect  quiet  ob- 
served. Ip  other  cases,  the  patient  may  be  allowed  to  move 
about  the  bed.  During  this  time  spinal  fomentations  may  be 
applied  twice  daily,  followed  by  the  heating  spinal  compress. 
The  warmth  of  the  limbs  should  be  maintained  by  the  hot  foot 
bath  or  hot  water  bottles.  It  is  necessary  that  the  patient  be 
given  tonic  treatment  to  keep  up  the  nutrition  and  invigorate 
the  circulation.  These  must,  however,  be  quite  mild,  such  as 
the  wet  hand  rub  and  moderately  cold  mitten  frictions.  Later, 
light  massage  to  the  limbs  may  be  used. 

As  soon  as  the  necessity  for  absolute  rest  is  past,  in  the 
chronic  stage  when  spasticity  becomes  marked,  nothing  has 
proven  so  helpful  as  the  prolonged  neutral  or  warm  bath.  In 
those  cases  in  which  cure  is  possible  this  measure  is  almost  a 
specific.  The  patient  should  be  made  very  comfortable  in  the 
tub  by  using  a  sheet  hammock,  rubber  pillows,  etc.  The 
temperature  of  the  water  should  be  from  95° — 97°  F.  It  must 
feel  slightly  warm  to  the  patient.  At  first  the  bath  may  be 
twenty  minutes  to  an  hour  in  length,  gradually  increasing  the 
time  up  to  three  or  four  hours  of  continuous  immersion  daily. 
Even  six  hours  in  the  neutral  bath  may  prove  beneficial. 


S12  SEDATIVE  EFFECTS 

Where  the  necessary  facilities  can  be  had,  the  continuous  flow- 
ing bath  is  a  most  grateful  substitute.  The  gentle  motion  of 
the  water  appears  to  add  much  to  the  effect.  The  salutary 
effects  are  manifest  in  a  lessened  degree  of  rigidity,  the  limbs 
become  more  supple  and  can  be  separated  to  a  greater  extent. 
In  order  to  obtain  any  permanent  benefit,  the  patient  must 
submit  to  treatment  for  many  months. 

In  the  subacute  stage,  positive  galvanism  to  the  spine  may 
be  useful.  During  this  time  mild  alternating  hot  and  cold 
applications  may  be  used  to  the  part  of  the  spine  affected. 
Later  in  the  disease,  prolonged  neutral  baths  give  better 
results. 

LOCOMOTOR  ATAXIA 

In  the  treatment  of  tabes  dorsalis,  we  are  concerned  chiefly 
with  the  first  two  stages,  the  initial  or  pre-ataxic  and  the  ataxic.  . 
In  the  paralytic  or  third  stage,  there  is  little  that  can  be  done 
except  to  make  the  patient  comfortable  and  treat  symptoms  as 
they  arise. 

In  the  pre-ataxic  stage  the  patient  must  be  put  to  rest.  This 
may  be  accomplished  by  restricting  or  prohibiting  exercise.  It 
is  usually  best  to  proscribe  exercise  altogether  for  a  time.  The 
wheel  chair  may  be  used  or,  if  thought  best,  the  patient  may  be 
put  to  bed  for  two  or  three  months.  Simple,  regular  habits  are 
imperative.  During  the  period  of  rest,  the  patient  may  be 
treated  by  fomentations  to  the  spine,  cold  mitten  frictions  and 
the  warm  bath.  Dana  recommends  that  this  latter  be  given 
for  ten  to  twenty  minutes  daily  and  followed  by  a  single  cold 
pour  to  the  spine  and  rubbing.  The  object  of  treatment  during 
this  stage  is  to  keep  up  the  patient's  general  nutrition  and  afford 
rest,  both  mental  and  physical,  so  as  to  relieve  the  tax  on  the 
spinal  nerves. 

If  the  progress  of  the  disease  can  be  stayed,  the  treatment 
outlined  for  the  ataxic  stage  may  be  ventured  upon,  beginning 
mildly.  The  Fraenkel  exercises  may  now  be  begun.  These 
should  at  first  consist  of  the  more  simple  movements  and  the 
effort  restricted  to  a  few  minutes.  Later  on,  as  coordination 
improves,  they  may  be  more  prolonged  and  made  up  of  more 
complicated  exercises. 


LOCOMOTOR  ATAXIA  313 

Vigorous  spinal  tonics  should  be  used  during  the  ataxic  stage 
unless  the  patient  is  becoming  rapidly  worse.  Alternate  hot 
and  cold  to  the  spine  by  means  of  the  fomentation  and  ice  may 
be  used  daily,  or  this  may  alternate  with  the  Charcot  (cold  per- 
cussion) douche  to  the  spine,  or  hot  and  cold  douche  to  the 
spine.  These  applications  should  be  persisted  in  for  months. 
The  long  static  spark  to  the  lower  spine  and  legs  may  be  used 
at  the  same  time,  say  thrice  weekly.  Galvanic  currents  are 
also  beneficial.  It  must  be  remembered  that  not  all  cases  are 
susceptible  of  any  marked  improvement.  The  plans  outlined 
above  have  proven  very  satisfactory  in  the  hands  of  many 
neurologists.  Nearly  all  agree  that  mercurial  treatment  is 
harmful  unless  symytoms  of  active  syphilis  still  exist.  Even 
in  this  case  bad  results  have  frequently  been  reported,  and  some 
observers  believe  that  antisyphilitic  medication  may  be  the 
direct  cause  of  tabes. 

For  the  arthritic  complications  ( Charcot' s  joint)  alternate  hot 
and  cold  applications  for  the  purpose  of  maintaining  the  local 
nutrition  and  improving  the  circulation  will  be  found  helpful. 
These  may  be  given  by  means  of  the  revulsive  compress,  alter- 
nate pours,  or  alternate  hot  and  cold  immersions.  Surgical 
treatment  has  proven  useful  in  skilled  hands  in  remedying  the 
deformities  and  restoring  the  usefulness  of  the  affected  joint. 
For  painful  joints,  very  hot  fomentations  may  be  given,  fol- 
lowed by  the  heating  compress. 

The  treatment  of  the  various  crises  is  unsatisfactory.  They 
may  at  times  be  relieved  by  local  hot  applications.  All  forms 
of  treatment,  including  hypnotics,  may  fail.  The  same  may 
be  said  of  the  lightening  pains.  Building  up  the  general  vital- 
ity of  the  patient  will  tend  to  remedy  these  distressing  condi- 
tions. 

PARENCHYMATOUS  GOITER 

The  pathology 5  and  morbid  physiology  of  parenchymatous  or 
exophthalmic  goiter  must  be  fully  understood  if  medical  treat- 
ment is  to  be  conducted  to  produce  the  best  possible  results. 
Exophthalmic  goiter  is  now  considered  to  be  due  to  hypertrophy 

5    See  articles  on  goiter  among  Collected  Papers  by  the  Staff  of  St.  Mary's  Hospital. 

1905—1909. 


S14  SEDATIVE  EFFECTS 

and  hyperactivity  of  the  thyroid  gland.  The  disease  is  better 
described  as  hyperthyroidism.  The  thyroid  is  one  of  the  duct- 
less glands  producing  an  internal  secretion.  The  exact  chemi- 
cal nature  of  this  secretion  is  not  known.  It  is  believed  to  be 
closely  associated  with  some  iodine  compound.  It  is  one  of 
that  class  of  substances  known  as  chemical  messengers  or  har- 
mones.  It  exercises  a  special  influence  over  certain  functions. 
In  infancy  the  absence  of  the  gland  is  marked  by  the  condition 
known  as  cretinism,  in  which  both  the  mind  and  the  body  re- 
main in  an  undeveloped  state.  In  adult  life  atrophy  or  removal 
of  the  gland  produces  the  condition  known  as  myxedema,  or 
cachexia  strumipriva.  In  these  conditions  mental  activity  is 
below  par,  cerebration  is  exceedingly  slow  and  all  bodily  move- 
ments are  deliberate  and  physical  activity  much  depressed. 
The  opposite  condition,  known  as  hyperthyroidism,  caused 
either  by  hypertrophy  of  the  glandular  tissue  or  by  giving  large 
doses  of  thyroid  extract,  produces  a  train  of  symptoms  just  the 
opposite  of  the  above.  The  patient  is  nervous,  restless,  irrit- 
able, and  may  be  subject  to  insomnia.  There  is  a  fine  tremor 
of  the  fingers  when  the  hand  is  held  away  from  any  support 
with  the  digits  spread.  During  the  early  part  of  the  disease, 
mental  activity  is  excessive,  ideation  is  rapid,  and  all  the  brain 
functions  are  increased  in  acuity.  If  intoxication  becomes  in- 
tense, the  pulse  may  be  very  rapid,  running  from  100  or  120  to 
160  or  more  per  minute;  the  skin  is  usually  warm  and  moist, 
being  covered  with  perspiration  the  most  of  the  time.  The 
blood-vessels  are  dilated.  Catabolic  changes  are  increased  and 
hastened  as  shown  by  the  fever  and  increase  in  the  excretion  of 
nitrogen.  There  is  a  feeling  of  languor,  and  asthenia  may  be- 
come very  marked.  In  the  gland  itself,  the  colloid  material  is 
deficient  in  amount,  there  is  an  increase  in  the  number  of 
secreting  cells,  even  to  the  filling  of  the  alveoli  with  cells;  the 
blood-vessels  of  the  gland  are  dilated  and  may  be  increased  in 
number.  Later,  the  parenchymatous  cells  degenerate  (cyto- 
lysis)  liberating  a  large  amount  of  thyroid  secretion;  the  most 
aggravated  symptoms  may  be  present  while  this  is  going  on. 
The  stethoscope  applied  over  the  gland  frequently  detects  a  sys- 
tolic bruit.  Owing  to  this  increased  vascularity  and  the  hyper- 


HYPERTHYROIDISM  315 

trophy  of  the  parenchytnatous  tissue,  the  thyroid  is  enlarged. 
Later  in  the  disease  the  eyes  become  prominent,  the  lids  are 
closed  with  difficulty,  and  the"  eyes  feel  dry.  It  is  supposed  that 
the  exophthalmia  is  due  to  dilatation  of  the  blood-vessels  in  the 
orbit. 

It  will  be  seen  that  these  conditions  set  forth  the  necessity 
for  treatment  directed  toward  decreasing  and  depressing  the 
activity  of  the  thyroid  gland.  In  the  spontaneous  cure  of 
this  condition,  the  colloid  material  increases  in  amount,  pro- 
ducing pressure  upon  the  parenchymatous  cells,  thus  causing 
their  atrophy.  The  increase  of  the  fibrous  stroma  of  the  gland 
has  the  same  effect.  In  these  facts  lies  the  rationale  of  the 
beneficial  action  of  the  X-ray.  It  has  a  specific  effect  in  des- 
troying or  causing  atrophy  of  highly  differentiated  tissue,  while 
it  favors  the  production  of  connective  tissue.  X-ray  exposures 
should  not  be  given  so  frequently  as  to  cause  unduly  rapid  dis- 
integration of  the  secreting  cells,  in  which  case  thyroid  intoxi- 
cation may  ensue.  The  vascularity  of  the  gland  must  also  be 
decreased. 

Albert  Kocker  makes  the  following  statements: 6  "By  reduc- 
ing the  hypertrophic  thyroid  tissue  or  reducing  its  blood  supply, 
we  reduce  the  possibility  of  too  extensive  reaction  to  the  pri- 
mary cause  and  also  enable  the  gland  to  adapt  itself  to  coun- 
teract new  outbreaks  of  primary  causes  which  a  nervous  subject 
can  easily  show. 

' '  The  fact  that  increased  vascularization  is  indispensable  for 
the  development  of  the  disease  also  proves  that  what  reduces 
vascularization  prevents  its  development. 

At  the  same  time  it  is  necessary  to  slow  the  heart  rate  and 
restore  the  blood-vessels  to  their  normal  tone.  While  all  cases 
will  not  respond  to  the  same  treatment,  or  even  to  different 
measures  arranged  in  different  ways,  yet  in  general,  the  treat- 
ment should  consist  of  the  means  making  up  the  following  pro- 
gram: An  ice  cap  should  be  placed  over  the  goiter  almost  con- 
tinuously or  for  thirty  minutes  to  an  hour  from  two  to  five  times 
a  day.  These  cold  applications  reflexly  contract  the  blood  - 


6    Surgical  Treatment  of  Exophthalmic  Goiter— Journal  of  American  Medical  Associa- 
tion, October  12,  1907,  pp.  1242—1243. 


S16  SEDATIVE  EFFECTS 

vessels  of  the  gland,  thus  decreasing-  its  vascularity  and  the 
amount  of  blood  in  the  gland.  They  also  tend  to  inhibit  or 
depress  the  glandular  activity,  decreasing  the  formation  of  the 
internal  secretion.  At  the  same  time,  an  ice  bag  should  be 
applied  to  the  precordia  in  much  the  same  manner  and  for  the 
same  length  of  time  as  the  ice  bag  to  the  goiter.  It  may  be 
found  convenient  to  alternate  these  applications,  keeping  the 
ice  bag  over  the  goiter  for  thirty  minutes,  then  applying  it  to 
the  heart  for  the  same  length  of  time,  then  reapplying  it  to  the 
goiter;  these  alternations  being  continued  more  or  less  during 
the  entire  day.  The  vaso-dilatation  and  warm  moist  skin  re- 
quire some  treatment  which  will  restore  the  vessels  to  their 
normal  tone  and  check  the  over-activity  of  the  sweat  glands. 
This  is  best  accomplished  by  the  cold  mitten  friction.  It  should 
be  given  from  one  to  three  times  daily.  Many  of  the  princi- 
ples governing  the  treatment  of  organic  heart  disease  are  in- 
volved in  the  treatment  of  parenchymatous  goiter.  The  cold 
friction,  by  restoring  the  peripheral  vessels  to  their  normal  tone, 
assists  the  heart  action  and  so  reduces  the  rate. 

The  vascular  conditions  present  in  exophthalmic  goiter  and 
the  therapeutic  indications  to  be  derived  therefrom  are  very 
ably  discussed  by  James  Mackenzie '  from  whom  we  quote  the 
following: — 

'  The  essential  features  arising  from  the  circulation  in  many 
cases  of  exophthalmic  goiter,  it  seems  to  me,  are  the  abnormal 
and  persistent  dilatation  of  the  arterioles,  and  a  heart  acting 
with  a  force  relatively  great  to  the  resistance  opposed.  These 
are  indicated  by  the  rapid  and  forcible  pulse-wave  felt  by  the 
finger,  and  the  visible  pulsation  of  the  superficial  arteries  and 
the  carotid.  The  corresponding  sphygmographic  features  are 
a  high  upstroke  and  a  rapid  fall,  so  that  the  dicrotic  notch  is 
near  the  base  line.  The  rate  of  the  pulse  may  be  greatly  in- 
creased, up  to  140  to  160  per  minute.  The  same  factors — the 
unusually  forcible  injection  of  the  blood  into  the  arteries  of  low 
blood  pressure— are  present  in  aortic  regurgitation.  Though 
the  beating  of  the  carotid  is  due  to  similar  causes  in  the  two 
cases,  the  low  arterial  pressure  at  the  end  of  the  diastole  is 

7    Diseases  of  the  Heart,  Second  Edition,  p.  133. 


HYPERTHYROIDISM  317 

different.  In  exophthalmic  goiter  the  dilatation  of  the  arterioles 
and  capillaries  is  the  sole  cause,  whereas  in  aortic  regurgitation 
there  is  in  addition  the  backward  flow  into  the  ventricle  through 
the  incompetent  valves.  The  condition  of  the  circulation  in 
exophthalmic  goiter  is  also  comparable  to  that  in  some  forms  of 
sthenic  fever,  where  the  heart  beats  forcibly  and  the  arteries  are 
relaxed. 

"Another  evidence  of  the  relaxation  of  the  arterioles  is  to  be 
found  in  the  subjective  sensation  of  warmth  felt  by  some  suf- 
ferers from  exophthalmic  goiter.  T*hey  rarely  complain  of  cold 
in  winter,  however  lightly  clad  they  are,  and  this  is  not  infre- 
quently the  cause  of  matrimonial  disputes,  for  while  the  ailing 
wife  feels  warm  in  bed  during  winter  with  few  blankets,  the 
healthy  husband  feels  the  cold  keenly.  This  feeling  of  warmth 
has  supplied  me  with  the  indications  for  the  only  treatment 
of  this  class  of  case  that  I  have  found  both  grateful  and  bene- 
ficial to  the  patient,  namely,  the  periodic  stimulation  of  the 
vasomotor  nerves  by  cold  baths." 

The  patient  should  be  kept  at  absolute  rest  until  the  pulse 
has  returned  to  nearly  normal.  Freedom  from  mental  excite- 
ment and  worry  are  fully  as  necessary  as  physical  rest.  In 
fact,  overtaxation  of  the  mental  powers,  nervous  excitement, 
etc.,  are  often  contributing  factors  in  the  causation  of  the  dis- 
ease and  may  constitute  the  immediate  cause.  In  some  cases 
it  may  seem  best  to  employ  some  of  the  sedative  measures, 
such  as  fomentations  to  the  spine  and  the  neutral  bath.  Usually 
both  of  these  treatments  are  contraindicated.  If  the  feet  re- 
main cold  much  of  the  time,  the  alternate  hot  and  cold  foot 
bath  or  alternate  hot  and  cold  douche  to  the  feet  should  be  used. 

We  have  yet  to  see  a  case  which  has  not  been  brought  to  a 
successful  issue  when  these  measures  have  been  applied  early, 
and  have  seen  complete  restoration  in  cases  that  have  come 
under  treatment  later  in  the  disease  when  the  pulse  reached 
160,  while  the  patient  was  exceedingly  nervous  and  unable  to 
sleep,  and  there  was  very  marked  exophthalmia  together  with 
a  large  goiter.  Those  cases  which  come  on  after  thirty  respond 
much  more  readily  to  treatment  than  when  the  disease  occurs 
in  younger  adults  or  under  twenty  years  of  age.  But  it  is  also 


Sis  SEDATIVE  EFFECTS 

true  there  is  a  natural  tendency  to  recovery  among  young- 
adults,  nineteen  out  of  twenty  recovering-  without  much 
treatment  but  rest.  Hyperthyroidism  beginning  in  persons 
from  eighteen  to  twenty  years  of  age  is  likely  to  run  a  course 
of  three  or  four  years  and  end  in  a  spontaneous  cure.  Opera- 
tive interference  will  be  much  less  frequently  necessary  when 
these  measures — rest,  hydrotherapy,  etc. — are  given  a  thorough 
trial  by  those  experienced  in  their  use. 

METHODS  FOR  THE  RELIEF  OF  PAIN 
Deep-Seated  Inflammations 

Those  treatments  which  have  already  been  outlined  for  the 
relief  of  congestion  and  inflammation  in  internal  org-ans  are  also 
most  effective  in  relieving  the  pain  occasioned  by  the  inflam- 
mation. In  the  majority  of  cases,  derivation  by  collateral  heat, 
together  with  cold  directly  over  the  part,  is  used  to  relieve  the 
congestion  and  pain.  In  others,  hot  applications  alone  are 
used.  This  is  true  of  pleurisy,  in  which  cold  applications  in- 
crease the  pain.  In  many  cases  the  pain  is  relieved  best  by 
very  hot  applications  applied  directly  over  the  seat  of  pain.  It 
has  already  been  mentioned  that  cold  may  be  used  over  an  in- 
flammatory process  in  soft  tissue,  while  in  bony  parts  it  is  nec- 
essary to  use  hot  applications  directly  over  the  seat  of  the  pain. 
In  the  case  of  osteomyelitis  and  usually  in  mastoiditis,  cold 
applications  or  the  ice  bag  applied  over  the  inflamed  part  in- 
creases the  pain.  When  an  inflammation  has  gone  on  to  the 
formation  of  an  abscess,  cold  applications,  especially  the  ice  bag-, 
have  very  little  influence  on  the  pain  as  far  as  relieving  it  is 
concerned,  and  may  make  it  worse.  Fomentations  over  an  ab- 
scess may  relieve  the  pain  for  a  time,  but  this  does  not  last  as 
long  as  the  relief  afforded  previous  to  the  formation  of  the 
abscess. 

In  order  to  decrease  the  throbbing-  pain  of  an  inflammatory 
process  or  collection  of  pus  in  the  bone,  it  is  best  to  apply  the  ice 
bag  over  the  large  artery  supplying  the  inflamed  part.  The 
relief  of  the  pain  in  this  case  is  brought  about  chiefly  by  reduc- 
ing the  congestion.  If,  at  the  same  time,  a  very  hot  fomenta- 
tion is  applied  over  the  part,  the  effect  is  intensified  by  the 
specific  pain-relieving  action  of  the  heat. 


RELIEF  OF  PAIN  319 

Superficial  Inflammation 

In  the  early  stage  of  a  superficial  inflammation,  a  prolonged 
cold  application  is  usually  very  effective  in  relieving-  the  pain. 
This  should  be  accomplished  by  immersion  in  cold  water  or  ice 
water  or  by  the  use  of  the  ice  bag.  Later  on,  it  will  be  found 
that  very  hot  applications  more  effectively  relieve  the  pain. 
Either  very  hot  fomentations  or  hot  immersion  may  be  used. 
Sometimes  the  neutral  or  warm  pour  is  very  grateful,  there 
seeming-  to  be  an  added  effect  from  the  affusion  that  is  not  ob- 
tained by  quiet  immersion.  The  production  of  fluxion  by  alter- 
nate extreme  hot  and  cold  immersion  is  productive  of  good 
results  where  there  is  not  much  throbbing  pain. 

Gastric  or  Duodenal  Ulcer 

It  is  often  the  case  that  the  pain  is  worse  during  the  time 
that  there  is  little,  if  any,  hemorrhage  from  the  ulcerated  sur- 
face. In  case  hemorrhage  of  any  moment  occurs,  it  is  neces- 
sary to  use  some  cold  applications,  such  as  cracked  ice  by 
mouth  or  the  ice  bag  over  the  stomach.  Otherwise,  the  pain 
is  best  relieved  by  very  hot  fomentations  applied  to  the  epigas- 
trium, or  the  full  hot  trunk  pack.  These  applications  my  be 
followed  by  either  the  moist  abdominal  girdle  or  by  the  heating 
wet  sheet  trunk  pack.  The  effect  of  these  applications  is  tore- 
lax  the  musculature  of  the  stomach  and  so,  by  decreasing  peri- 
stalsis, relieve  the  pain  incident  to  muscular  contractions. 

Rectal  Ulcer 

The  same  principles  apply  here  as  above.  The  pain  is  most 
effectively  relieved  by  applications  which  relax  the  bowel,  thus 
decreasing  the  movement  and  consequent  irritation  of  the  ulcer- 
ated surface.  This  may  be  accomplished  by  the  hot  enema  or 
fomentations.  Usually  the  hot  sitz  bath  is  much  more  effective. 

Hemorrhoids 

Two  different  plans  may  be  followed  in  relieving  the  pain 
occasioned  by  rectal  varicose  veins.  Very  hot  applications  are 
effective  in  relieving  the  pain,  but  these  have  no  tendency  to 
decrease  the  size  of  the  hemorrhoids.  On  the  contrary,  they 


320  BED  A  TIVE  EFFECTS 

may  increase  the  dilatation  of  the  veins,  stasis  of  blood  and  con- 
sequent pain.  Of  the  hot  applications  which  may  be  used,  the 
very  hot  sitz  bath  is  most  effective.  In  case  facilities  for  this 
are  not  at  hand,  fomentations  may  be  used. 

For  permanent  results,  we  prefer  cold  applications,  such  as 
the  prolonged  cold  sitz  bath,  ice  bag-  to  the  perineum,  also  the 
hot  and  cold  perineal  spray.  To  be  effective,  these  treatments 
should  be  repeated  once  or  twice  daily  for  several  weeks.  The 
temperature  of  the  cold  sitz  bath  may  be  decreased  gradually 
as  the  patient  is  able  to  bear  it. 

Neuralgia 

The  classification  of  neuralgias  into  two  types  has.  aided  in 
the  treatment  of  this  condition.  Simple  neuralgias,  not  due  to 
pressure  from  tumors,  exostoses,  etc.,  we  have  classified  as 
either  toxic  or  inflammatory.  By  the  term  toxic,  we  designate 
such  neuralgias  as  are  due  to  rheumatic  (uric  acid)  diathesis, 
or  some  form  of  auto-intoxication.  The  essential  element  in 
the  causation  of  this  form  of  neuralgia  is  the  circulation  of  tox- 
ins in  the  body,  or  the  accumulation  of  toxins  about  nerve 
centers  or  nerve  trunks. 

By  the  term  inflammatory  neuralgia,  we  understand  such 
conditions  as  are  due  to  actual  inflammation,  usually  such  in- 
flammations as  pass  through  the  regular  stages  of  an  inflamma- 
tory process,  from  acute  to  chronic.8  It  may  often  be  difficult, 
impossible,  and  in  some  cases,  unnecessary  to  make  these  dis- 
tinctions. It  will  be  readily  understood  that  some  of  the 
changes  occurring  in  an  ordinary  inflammation  are  produced  by 
the  accumulation  of  toxins  about  nerve  trunks.  Local  edema 
of  tissues  occurs  in  both  cases. 

1.  Toxic  Neuralgia.  Where  there  is  a  local  accumulation  of 
toxins  about  a  nerve  trunk,  it  appears  that  hot  applications 
most  effectually  relieve  the  pain  while  cold  increases  the  pain. 
Nitrogenous  extractives  and  other  nitrogenous  toxins  are  sol- 
uble with  difficulty.  They  are  more  readily  dissolved  in  hot 
water.  Since  prolonged  hot  applications  raise  the  local  tem- 

8  The  term  inflammatory  neuralgia  is  not  intended  as  a  synonym  for  neuritis,  such  as 
alcoholic  neuritis,  which  latter  results  in  nerve  degeneration  and  gives  the  R.  D.  on 
electric  test. 


NEURALGIA  321 

perature  of  the  part  treated,  it  might  be  supposed  that  the  tox- 
ins are  rendered  more  diffusible,  and  hence  may  be  gotten  rid 
of  more  rapidly.  The  chilling:  of  the  tissues  would  result  in  a 
greater  precipitation  of  these  sparingly  soluble  substances  and 
so  tend  to  increase  the  pain.  It  must,  of  course,  be  remem- 
bered that  heat 'has  a  specific  pain-relieving  action  which  is 
possibly  greater  in  importance  than  any  action  it  may  have 
upon  the  local  accumulation  of  toxins.  The  pain  of  toxic  neu- 
ralgia may  be  relieved  by  very  hot  fomentations  or  the  local 
electric  light  bath.  For  a  prolonged  application,  the  hot  water 
bottle  is  very  serviceable.  Any  of  these  applications  may  be 
followed  by  the  heating  compress.  This  should  be  wrung  from 
tepid  or  cool  water;  rarely,  if  ever,  from  ice  water.  The  mode 
and  duration  of  the  hot  application  should  be  varied  according 
to  the  character  and  location  of  the  pain. 

In  treating  sciatica,  the  hot  fan  douche  is  a  very  effective 
means.  Very  hot  affusions  may  be  used.  Sometimes  the  hot 
percussion  douche  is  more  effectual.  It  must  always  be  borne 
in  mind  that  the  cure- of  the  case  requires  the  entire  removal  of 
the  cause.  For  this  reason,  a  regime  embodying  the  prolonged 
use  of  tonic  hydrotherapy,  general  eliminative  treatment,  and 
proper  diet,  is  necessary  for  the  permanent  relief  of  neuralgias. 
We  have  found  the  use  of  positive  galvanism  of  very  great 
benefit  in  neuralgia,  especially  in  facial  neuralgia  of  severe 
chronic  type. 

2.  Inflammatory  Neuralgia.  A  very  different  plan  should  be 
followed  where  the  pain  in  nerve  trunks  is  due  to  real  inflam- 
mation. Prolonged  cold  applications,  even  to  almost  freezing 
the  part,  give  better  results  than  hot  applications.  For  this 
purpose,  it  is  sometimes  recommended  to  use  the  ethyl  chloride 
spray.  Cold  may  also  be  applied  by  means  of  the  ice  bag,  ice 
pack  or  ice  compress.  These  should  not  be  too  thickly  covered 
and  should  be  left  in  place  a  sufficient  length  of  time  to  mater- 
ially lower  the  temperature  of  the  part  treated.  Sometimes 
derivation  by  direct  cold  and  collateral  heat  is  very  effective. 
Cold  affusions  may  also  be  used.  The  pain  of  an  inflam- 
matory sciatica  is  often  benefited  by  the  alternate  hot  and  cold 

21 


S22  SEDATIVE  EFFECTS 

douche  applied  up  and  down  the  thigh  over  the  sciatic  nerve. 
In  all  cases  of  neuralgia,  it  is  best  to  make  repeated  search 
for  the  cause.  While  the  majority  of  cases  of  facial  and  other 
neuralgias  are  not  due  to  conditions  which  can  b?  remedied  by 
operation,  yet  this  is  sometimes  the  case.  In  this  connection,  it 
might  be  mentioned  that  operation  for  facial  neuralgia  is,  in  the 
majority  of  cases,  not  only  a  failure,  but  an  actual  detriment  to 
the  patient.  The  relief  of  the  pain  is  merely  temporary  and, 
because  of  shock,  nerve  exhaustion,  etc.,  repeated  operations 
render  the  patient  much  more  susceptible  to  pain. 

Myalgia — Lumbago 

Lumbago  is  the  most  common  myalgia,  and  is  that  treated  of 
here.  It  follows  colds  and  exposure  to  cold  and  dampness. 
The  actual  cause  and  the  morbid  condition  are  not  well  under- 
stood. The  treatment  differs  considerably  from  other  sedative 
measures,  in  that  the  best  results  are  obtained  by  the  most 
vigorous  stimulation.  We  have  obtained  almost  invariably  un- 
failing results  from  the  use  of  large  very  hot  fomentations  to 
the  lumbar  spine  followed  by  the  alternate-  hot  and  cold  percus- 
sion douche  to  same  region  and  heavy  massage  or  vibration  to 
the  large  lumbar  muscles.  About  once  a  day  the  negative 
static  spray  or  short  static  spark  may  be  used;  also  slow  sinu- 
soidal or  static  surging  to  produce  vigorous  muscular  contrac- 
tions. In  acute  cases  these  treatments  bring  prompt  relief; 
and  in  chronic  cases,  in  a  few  days  or  a  week  or  two. 

Tenesmus, — Rectal  or  Vesical 

Pain  in  hollow  muscular  organs  is  chiefly  due  to  the  con- 
tractions of  the  muscular  tissue.  This  activity  of  the  muscular 
wall  increases  the  irritation  arising  in  the  mucous  membrane. 
To  relieve  tenesmus  of  the  bladder  or  rectum,  we  have  found 
the  hot  sitz  bath  the  most  effectual.  The  heat  should  be  pro- 
longed a  sufficient  length  of  time  to  fully  relieve  the  pain. 
Only  a  brief  dash  of  cold  water  should  be  given  at  the  close. 
In  some  cases  it  should  be  omitted  entirely.  Large  fomenta- 
tions or  the  hot  hip  pack  may  be  used.  In  rectal  tenesmus,  a 
small  hot  enema  or  the  starch  enema  affords  relief.  The  enema 


DYSMENORRHEA  323 

should  be  given  before  fomentations  or  the  hot  sitz  is  applied. 
Cold  applications  stimulate  muscular  contraction,  and  hence 
increase  the  pain. 

Dysmenorrhea 

The  condition  here  is  somewhat  similar  to  a  tenesmus.  It  is 
most  frequent  in  sharp  anteflexions  of  the  uterus,  or  may  be 
occasioned  by  chilling-.  In  order  to  afford  immediate  relief,  it 
is  necessary  to  relax  the  musculature  of  the  organ.  Cold  causes 
contractions  of  the  uterine  muscle  and  so  prevents  the  out- 
flow of  blood,  while  hot  applications  relax  the  muscle.  Often 
simple  fomentations  are  sufficient  to  afford  relief.  It  may, 
however,  be  necessary  to  use  the  short  hot  sitz  bath.  No  cold 
treatment  should  follow  it.  The  application  of  the  unwrapped 
ice  bag  to  the  sacrum  may  be  used,  accompanying  some  hot 
application  to  the  feet  and  legs.  It  may  be  necessary  to  con- 
tinue this  twenty  or  thirty  minutes.  Hot  applications  in  front 
may  be  used  at  the  same  time.  The  ice  bag  when  applied  an- 
teriorally  has  the  opposite  effect,  that  is,  it  causes  contraction 
rather  than  relaxation.  Probably  the  explanation  of  the  action 
of  the  ice  bag  to  the  sacrum  in  relaxing  the  uterus,  as  has 
been  pointed  out,  lies  in  the  fact  that  the  posterior  area  is  in 
less  perfect  reflex  relation  with  the  uterus;  and  for  this  reason, 
the  reflex  is  easily  paralyzed,  the  effect  then  being  opposite  to 
that  which  we  usually  expect  from  the  ice  bag.  The  use  of  the 
ice  bag,  however,  is  not  as  satisfactory  as  hot  applications  alone. 

In  addition  to  these  measures,  the  hot  enema  and  very  hot 
vaginal  irrigation  may  be  administered  prior  to  the  use  of  the 
fomentation  or  hot  sitz.  In  the  case  of  suppressed  menses 
with  pain,  when  due  to  colds  or  exposure  to  dampness,  it  is  well 
to  use  a  hot  foot  bath;  or  better,  hot  leg  bath,  together  with 
some  local  hot  applications.  This  reduces  the  extreme  pelvic 
congestion,  renders  the  outflow  easier,  and  so  relieves  pain. 

Colic, — Renal,  Biliary,  Intestinal 

The  pain  of  renal,  biliary,  and  intestinal  colic  is  largely  due 
to  spasmodic  contraction  of  the  non-striped  muscle  of  these 
parts.  The  irritation  of  the  mucous  membrane  by  the  calculus 
stimulates  the  muscle  to  contract.  To  relieve  pain  from  cal- 


324  SEDATIVE  EFFECTS 

culus  or  the  pain  of  intestinal  colic,  it  is  necessary  to  use  large 
hot  applications  in  order  to  secure  perfect  relaxation. 

1.  Renal  and  Biliary  Colic.     It  is    usually    considered    that 
morphine  is  absolutely  essential  in  these  conditions.      By  the 
use  of  the  full  hot  blanket  pack  or  hot  trunk  pack,  morphine 
may   often  be  entirely  dispensed  with.     If  the  pack  does  not 
fully  relieve  the  pain,  a  much  smaller  dose  of  morphine  than 
would  otherwise  be  required,  will  be  sufficient.     The  blanket 
should  be  wrung  from  boiling  water,  quickly  spread  out  on  the 
bed  over  a  dry  blanket  and  as  quickly  as  possible  wrapped  about 
the  patient.     A  thin  dry  blanket  may  be  used  next  the  patient 
if  it  seems  advisable.     It  is  not  necessary  to  include  the  arms 
in  the  pack.     A  hot-water  bottle  over  the  abdomen  and  spine 
bags  along  each  side  of  the  trunk  will  help  to  maintain  the  heat 
of  the  pack.     In  cases  where  the  pain  is  not  so  severe,  large 
fomentations  may  be  sufficient.      The  full  hot  tub  bath  gives 
good  results  in  some  cases.     Wherever  a  hot  application  is  much 
prolonged,  cold  compresses  should  be  applied  to  the  head  and 
neck.     No  cold  applications   whatever  should   follow  the  hot 
pack.     Even  a  very  brief  application  of  cold  may  bring  on  the 
pain. 

2.  Intestinal  Colic.     In  regard  to  the  causation  of  colicky  pain 
in  hollow  viscera  and  particularly  the  intestine  and  the  region 
to   which   it  is  referred,   Mackenzie  relates  an  interesting  ex- 
perience with  a  patient  on  whom  he  performed  an  intestinal  re- 
section without  anesthesia.      He   says,    "  It  turned  out  as   I 
had  expected,  and  I  was  able  to  break  down  numerous  old  and 
recent  peritoneal  adhesions,  to  detach  them  from  the  liver  and 
bowel,  to  resect  a  piece  of  bowel  and  mesentery,  and  to  stitch 
these  structures  without  the  patient  experiencing  the  slightest 
sensation.     But  I  found  that  he  occasionally  groaned  with  pain 
when  I  was  not  touching  him,  and  watching  to  see  the  cause  I 
found  that  the  upper  part  of  the  resected  bowel,  which  was  laid 
on  one  side  in  a  warm  aseptic  cloth,  occasionally  passed  into 
peristalsis,  contracting  from  a  wide  tube  to  a  thick  fleshy  rod; 
when  this  happened  the  patient  groaned  with  pain.     I  asked 
him  where  he  felt  the  pain,  and  he  passed  his  hand  invariably 
over   the   umbilical    region.      I  started  th.e  peristalsis  several 


BURNS  325 

times  by  slightly  pinching:  the  bowel,  and  each  time  the  patient 
felt  the  pain.  Here  before  my  eyes  was  the  cause  of  the  pain, 
and  the  seat  of  origin  of  the  pain  was  at  least  twelve  inches 
away  from  the  part  in  which  the  pain  was  felt. 

From  this  experience  the  following-  deductions  can  be  made : 
First,  that  the  stimuli  that  produce  pain  and  other  sensations  in 
the  external  body-wall  are  not  adequate  to  produce  these  sen- 
sations when  applied  to  the  viscera;  second,  that  violent  con- 
tractions of  non-striped  muscular  fibres  can  produce  pain,  but 
the  region  in  which  the  pain  is  felt  is  different  from  that  in 
which  the  contracting  muscle  lies."  9 

The  effect  of  hot  applications  in  these  cases  is  due  to  the  re- 
flex relaxation  of  the  intestinal  musculature,  and  hence  the 
relief  of  the  pain. 

When  intestinal  colic  is  due  to  poisoning  or  simple  diarrhea, 
it  is  well  to  begin  the  treatment  by  thorough"  cleansing  of  the 
intestinal  canal.  It  may  be  necessary  to  use  a  cathartic  in  order 
to  completely  remove  the  irritating  toxic  material.  Castor  oil 
is  very  satisfactory,  especially  in  children,  because  of  its  con- 
stipating after  effect.  In  all  cases,  hot  enemata  should  be  given 
until  the  lower  bowel  is  thoroughly  cleansed.  If  necessary, 
this  may  be  followed  by  the  starch  or  starch  and  laudanum  en- 
ema. Following  this,  the  most  effective  measure  for  the  relief 
of  the  pain  is  the  abdominal  fomentation.  These  should  be  re- 
peated until  the  pain  has  been  entirely  relieved.  The  hot-water 
bottle  may  be  used  between  treatments.  Fomentations  to  the 
abdomen  may  be  given  every  two  to  four  hours  or  as  frequently 
as  necessary. 

Burns 

In  the  case  of  burns  covering  a  somewhat  limited  area,  the 
dressings  usually  applied  are  sufficient  to  relieve  the  pain.  Cold 
immersion  relieves  the  pain  during  the  time  the  part  is  in  the 
cold  water.  It  has,  however,  been  our  experience  that  the  pain 
is  worse  after  removal  from  the  water.  On  the  contrary,  while 
hot  immersion  is  not  very  grateful  during  its  continuance,  its 
after  effect  is  better  than  that  of  cold  immersion.  A  neutral  or 


9  Mackenzie — Diseases  of  the  Heart,  pp.  34,  35. 


326  SEDATIVE  EFFECTS 

warm  pour  to  the  burned  part  is  very  effective  in  relieving-  the 
pain.  In  extensive  burns,  it  is  often  necessary  to  use  a  full 
immersion  bath  of  either  neutral  or  cool  water.  In  the  absence 
of  facilities  for  this,  a  prolonged  wet  sheet  pack,  renewed  by 
frequent  sprinkling-  with  cold  water,  may  be  used.  With  the 
exception  of  extensive  burns  or  where  the  pain  is  unbearable, 
we  do  not  greatly  favor  the  use  of  hydrotherapy  for  the  relief 
of  the  pain.  The  use  of  picric  acid  in  saturated  aqueous  solu- 
tion, followed  by  drying-  and  dusting-  the  part  with  stearate  of 
zinc,  has  given  such  good  results  in  the. relief  of  pain,  rapid 
dermatization,  and  healing-  that  we  use  it  as  a  routine  treatment. 

Sprains  and  Bruises 

Hot  applications,  including-  fomentations  and  hot  immersion, 
are  common  household  remedies  for  the  relief  of  pain  occa- 
sioned by  sprains  and  bruises.  These  applications  do  effectually 
relieve  the  pain  and  relax  the  muscles.  In  many  cases,  much 
better  results  may  be  obtained  by  the  prolonged  cold  immersion. 
This  reduces  the  congestion  and  helps  to  prevent  excessive  ex- 
udation of  serum  into  the  soft  tissues  about  the  sprained  part. 
Along  this  line,  we  may  draw  a  practical  lesson  from  the  method 
instinctively  pursued  by  wild  animals.  They  usually  seek  a 
stream  or  body  of  cold  water  and  stand  in  it  for  hours  at  a  time. 
Whatever  method  is  used  at  first,  after  a  day  or  two,  it  will  be 
found  advantageous  to  utilize  alternate  hot  and  cold  applica- 
tions, such  as  the  hot  and  cold  spray,  pour,  or  immersion. 
These  stimulate  the  circulation,  thus  hastening  the  absorption 
of  the  edema. 

Fractures 

There  are  two  objects  to  be  attained  by  hydriatic  applications 
in  fractures.  These  are  the  relief  of  the  pain  and  the  relax- 
ation of  the  muscles.  The  limb  should  be  enveloped  in  a  large 
fomentation  or  immersed  in  very  hot  water.  Care  should  be 
taken  that  a  burn  or  blister  does  not  result.  These  methods 
are  in  too  common  use  to  need  extensive  discussion.  It  will 
always  be  found  easier  to  set  a  bone  if  the  muscles  have  been 
thoroughly  relaxed  by  the  preliminary  use  of  hot  applications. 
The  same  principles  apply  to  the  reduction  of  hernia  by  taxis. 


HEADACHE  327 

Headache 

The  subject  of  headache  is  such  a  large  one  that  we  can  not 
enter  into  it  here  with  any  degree  of  completeness.  A  few 
principles  of  therapeutics  will,  however,  be  helpful  in  obtaining 
an  understanding  of  the  scientific  application  of  physiologic 
therapy  in  the  relief  of  this  condition.  In  order  to  give  these 
principles  with  the  least  possible  repetition,  we  have  adopted 
the  classification  of  J.  W.  Shiels:— 10 

I.  Functional  headaches. 

1.  Toxemic  headaches  (acute,  chronic). 

2.  Neuropathic. 

3.  Reflex. 

II.  Organic  headaches. 
III.    Circulatory  headaches. 

1.  Anemic. 

2.  Hyperemic  (active). 

3.  Hyperemic  (passive). 

The  above  is  very  much  abreviated.  As  given  by  Shiels, 
each  division  embraces  from  five  to  twelve  or  more  individual 
items — the  designations  of  morbid  conditions,  diseases,  or 
pathologic  states. 

Functional  Headaches.  The  acute  toxemic  headaches  of  acute 
infections,  acute  nephritis,  uremia,  diabetic  acidemia,  and  acute 
drug  poisonings,  are  best  relieved  by  direct  and  vigorous  treat- 
ment of  the  causative  diseases.  Ice  bags  .to  the  carotids  and  to 
the  base  and  vertex  of  the  brain  will  help  in  relieving  the 
accompanying  congestion. 

The  chronic  toxemic  headaches  of  gout,  rheumatism,  constipa- 
tion, torpid  liver,  and  other  diseases  affecting  metabolism,  are 
also  to  be  treated  by  treating  the  causative  disease.  But  in 
these  conditions  it  requires  patient,  persistent  effort  over  weeks 
or  months  of  time  in  order  to  produce  satisfactory  results. 
Out-of-door  life,  sunshine,  and  tonic  and  eliminative  hydro- 
therapy  will  do  much  to  remove  the  toxins  by  stimulating  their 
oxidation.  In  addition  to  this,  the  measures  recommended  for 
neuropathic  headaches  will  prove  helpful  in  relieving  or  miti- 

10    Shiels— California  State  Journal  of  Medicine,  November,  1909,  p.  401. 


SEDATIVE  EFFECTS 

gating  the  distress  until  more  permanent  results  can  be  secured 
by  the  removal  of  the  cause.  In  some  of  these  diseases  the 
headache  is  made  worse  by  an  accompanying  anemia  or  hyper- 
emia,  in  which  case  the  measures  recommended  below  for  these 
circulatory  conditions  should  also  be  used. 

Neuropathic  headaches  are  relieved  with  ease  or  difficulty 
according  as  they  are  of  short  or  long  standing,  /.  e. ,  as  to 
whether  or  not  they  have  become  habits,  appearing  periodi- 
cally. The  neurasthenic  headache  usually  responds  to  tonic 
hydrotherapy  and  out-of-door  life.  It  is  the  form  of  headache 
which  is  most  benefited  by  nerve  pressure  and  nerve  stimula- 
tion, spinal  and  head  massage.  It  is  in  these  neuropathic 
headaches  that  the  osteopath  acquires  a  justly  obtained  reputa- 
tion for  skill.  However,  any  thoroughly  trained  masseur  who 
has  acquired  a  fair  knowledge  of  anatomy  can  accomplish  the 
same  results  without  the  recital  of  osteopathic  dogmas  with 
which  the  osteopath  accompanies  his  treatment  and  by  which 
he  ties  his  patient  to  himself  and  his  creed,  greatly  to  the 
patient's  detriment  in  case  of  other  or  more  serious  maladies. 

Positive  galvanism  to  the  base  of  the  brain  or  forehead,  the 
positive  static  head  breeze,  or  mild  faradism  to  the  head,  are 
useful  in  certain  cases  of  neuropathic  headache. 

Migraine,  in  our  experience,  is  both  toxemic  (metabolic), 
hyperemic,  and  in  many  cases  reflex  (from  the  liver,  stomach, 
or  pelvis).  It  is  most  discouraging  and  unsatisfactory  to  treat 
as  far  as  immediate  rejief  is  concerned.  We  have  attained  suc- 
cess only  by  a  painstaking,  diligent,  and  often  prolonged  search 
for  the  cause.  If  it  is  the  expression  of  visceral  gout,  a  rigidly 
purin-free  diet  with  eliminative  and  tonic  hydrotherapy,  fresh 
air,  and  sunshine,  continued  for  months  or  years,  will  ulti- 
mately result  in  a  satisfactory  cure.  If  reflex,  the  diseased 
organ  or  function  must  be  sought  out  and  treated.  In  all  cases 
.out-of-door  work  is  one  of  the  most  beneficial  means  of  treat- 
ment. 

Organic  Headaches.  The  headache  of  acute  or  chronic 
meningitis  is  to  be  treated  in  the  same  way  as  any  headache 
due  to  acute  congestion.  The  results  are  less  satisfactory 
because  of  the  high  intracranial  pressure.  This  factor  may  be 


HEADACHES  329 

partially  or  wholly  eliminated  by  spinal  puncture,  except  in 
cases  where  the  foramen  of  Magendie  is  closed.  The  headache 
of  brain  tumor  yields  but  slightly  to  anything:  except  a  powerful 
hypnotic  or  analgesic  drug:.  In  all  cases  where  syphilis  may  be 
a  possible  cause,  potassium  iodide  should  be  used.  In  head- 
ache due  to  gumma  of  the  brain,  its  results  are  satisfactory  and 
usually  prompt. 

Circulatory  Headaches.  Anemic.  This  is  present  in  severe 
anemias  from  many  different  causes,  sometimes  in  convales- 
cence, and  in  blood  dyscrasias.  It  may  also  be  caused  by 
vascular  spasm.  The  most  satisfactory  treatment  is  alternate 
hot  and  cold  applications  to  the  head  given  as  described  under 
technique.  This  measure  occasions  a  more  active  circulation 
in  the  cerebral  vessels  by  stimulation  of  the  vessels  themselves 
through  their  vasomotor  nerves.  It  should  be  repeated  daily 
or  on  alternate  days  as  required.  Alternate  hot  and  cold  to 
the  spine  and  the  cold  mitten  friction  will  both  aid  in  stimulat- 
ing the  circulation. 

Hyperemic.  In  active  hyperemia  the  pain  is  often  throbbing 
in  character  and  the  face  is  flushed,  so  that  the  diagnosis  is  not 
difficult.  The  treatment  consists  in  depletion.  This  may  be 
secured  in  many  different  ways  applied  as  necessary  according 
to  other  conditions  present.  The  hot  foot  bath  with  ice  bags 
to  the  carotids  and  back  of  the  neck  is  a  routine  measure  and 
usually  results  in  relief.  When  due  to  excessive  brain  work, 
the  alternate  foot  or  leg  bath  or  the  alternate  hot  and  cold 
percussion  douche  to  the  feet  and  legs  is  more  beneficial.  It 
produces  depletion  by  collateral  fluxion.  In  some  cases  the  use 
of  simultaneous  hot  and  cold  to  the  head  is  best  designed  to 
relieve  the  hyperemia,  especially  where  there  is  also  a  toxemic 
factor  present. 

Passive  Congestion.  This  is  a  very  troublesome  form  of  head- 
ache, found  chiefly  in  cases  of  cold  in  the  head  (coryza).  Since 
passive  hyperemia  is  best  treated  by  fluxion,  the  headache 
present  with  this  condition  also  yields  best  to  the  application  of 
alternate  hot  and  cold  to  the  head,  the  same  as  recommended 
for  anemia  of  the  brain.  This  stimulates  the  circulation  and  so 
remedies  the  passive  congestion.  Since  the  brain  is  very 


SSO  SEDATIVE  EFFECTS 

susceptible  to  hyperemia,  the  treatment  should  be  accompanied 
by  the  hot  foot  bath  or  hot  leg:  pack  and  finished  by  a  cold  mit- 
ten friction  or  the  alternate  hot  and  cold  percussion  douche  to 
the  feet,  in  order  to  prevent  active  congestion  and  to  secure 
permanent  derivation. 

In  connection  with  the  subject  of  headache,  we  can  not  re- 
frain from  uttering:  a  caution  against  the  use  of  analgesics.  It 
is  true  that  patients  desire  and  often  demand  something  for 
immediate  relief.  The  relief  received,  the  patient  makes  no 
reform,  or  in  many  cases  no  attempt  at  reform,  and  obscure 
causes  are  not  searched  out.  The  headache  powder  is  repeated 
on  the  next  occurrence  of  the  headache,  and  in  a  very  short 
time  the  habit  is  formed.  It  is  then  "a  much  more  difficult 
matter  to  afford  temporary  relief  without  the  drug,  and  a  still 
more  difficult  matter  to  effect  a  permanent  cure. 

The  patient  had  better  have  suffered  a  little  temporary  dis- 
comfort and  pain,  and  have  yielded  to  the  physician's  advice  in 
starting  a  search  for  the  cause  and  instituting  a  method  of 
treatment  for  its  removal  and  the  correction  of  the  morbid 
habit.  Practically  all  headaches  other  than  organic,  and  even 
some  of  these,  may  be  entirely  remedied  by  persistent  and 
painstaking  endeavor. 


CHAPTER  XXII 
EXPECTORANT  EFFECTS 

nPHERE  is  a  definite  series  of  changes  accompanying  the  course 
A  of  such  conditions  as  colds,  acute  bronchitis,  and  simple 
croup.  In  all  congestions  and  inflammations  of  the  mucous  mem- 
brane of  the  respiratory  tract,  the  first  change  is  that  of  intense 
congestion  accompanied  by  swelling  and  turgescence  of  the  mem- 
brane which  is  dry  and  much  irritated.  In  this  condition  the 
cold  is  said  to  be  "tight"  because  of  the  extreme  irritation  and 
the  fact  that  the  dry  mucous  membrane  renders  gaseous  inter- 
change difficult.  Very  soon  there  begins  to  appear  a  secretion 
of  a  thick  tenacious  mucus,  accompanied  by  leucocytes.  Later, 
the  character  of  the  secretion  becomes  altered.  It  is  more 
fluid,  contains  frothy  mucus  and  is  more  purulent  in  nature. 
When  this  change  occurs,  the  cold  is  said  to  have  "  loosened." 
From  this  time  on,  expectoration  becomes  easier.  During  the 
first  stage  of  the  turgescence  of  the  mucous  membrane,  there  is 
no  expectoration.  Later,  there  is  a  very  small  amount  of  thick 
mucus  which  is  expectorated  with  difficulty;  and  after  the  cold 
has  thoroughly  loosened,  the  quantity  is  very  much  increased, 
while  the  sputum  is  quite  fluid. 

In  the  application  of  measures  designed  to  relieve  these 
conditions,  that  which  appears  most  rational  is  the  hastening  of 
this  series  of  changes  and  relieving  such  symptoms  as  pain  and 
cough.  During  the  first  stage,  that  is,  the  stage  of  congestion, 
and  the  second  stage  when  there  begins  to  be  a  secretion  of 
thick  mucus,  it  is  necessary  to  decrease  the  congestion  and 
increase  the  fluidity  of  the  secretion.  This  is  best  accomplished 
by  moist  heat,  such  as  the  inhalation  of  steam,  fomentations 
to  the  chest  and  throat,  hot  water  drinking,  the  heating  chest 

(331) 


SSH  EXPECTORANT  EFFECTS 

pack  or  some  general  sudorific  measure.  The  moist  heat 
dilates  the  blood-vessels  and  stimulates  the  activity  of  the 
mucous  glands,  so  that  they  produce  a  more  fluid  secretion. 
These  measures  should  be  continued  with  but  little  change 
until  the  symptoms  are  considerably  ameliorated.  Then  after 
the  first  day  it  is  best  to  employ  alternate  hot  and  cold  applica- 
tions, the  revulsive  compress,  cold  mitten  friction,  etc.,  in  order 
to  promote  resolution,  absorb  the  exudate,  and  prevent  further 
excessive  secretion.  This  is  best  accomplished  by  stimulating: 
the  circulation,  so  equalizing"  it  that  congestion  of  the  pulmon- 
ary mucous  membrane  and  the  mucous  membrane  of  the  nose 
and  throat  is  decreased.  These  measures  also  stimulate  the 
depth  of  respiration  and  increase  gaseous  interchange.  All 
sudorific  measures  ease  difficult  respiration  and  increase  the 
fluidity  of  expectoration.  The  following  are  the  most  useful 
measures  in  the  treatment  of  inflammations  of  the  respiratory 
tract: — 

1.  Russian  or  vapor  bath. 

2.  Inhalation  of  steam,  plain  or  medicated. 

3.  Fomentations  to  chest  and  throat,  or  the  hot  trunk  pack. 

4.  Heating  chest  pack  and  heating  throat  compress. 

5.  Hot  water  drinking. 

Several  of  these  may  be  combined:  for  example,  fomentations 
to  the  chest  and  throat  may  be  accompanied  by  hot  water 
drinking,  inhalation  of  steam,  and  the  hot  footbath.  Expec- 
torant effects  are  indicated  in  the  following  conditions: — 

1.  Colds. 

2.  Acute  bronchitis. 

3.  Chronic  bronchitis. 

4.  Asthma. 

5.  Croup. 

6.  Bronchiectasis. 

7.  Pulmonary  tuberculosis. 

Precautions.  All  of  the  applications  recommended  for  expec- 
torant effects  are  of  a  more  or  less  diaphoretic  nature,  and  con- 
sequently the  patient  is  predisposed  to  colds  and  there  is  greater 
liability  to  a  return  of  the  symptoms.  For  these  reasons,  it  is 
best  to  employ  such  measures  as  the  alcohol  or  witch-hazel  rub 


COLDS  333 

at  the  conclusion  of  the  sweating  measure,  or  some  mild  cold 
application,  such  as  the  wet  hand  rub  or  cold  mitten  friction. 
The  chest  should  be  protected  by  a  dry  chest  pack.  The  cloth- 
ing should  be  sufficient  to  provide  warmth,  and  the  patient 
should  be  cautious  about  exposure  to  drafts  and  dampness. 

ACUTE  CORYZA,  PULMONARY  CONGESTION, 
ACUTE  BRONCHITIS 

In  these  conditions,  it  is  necessary  to  accomplish  the  follow- 
ing results:  First,  relieve  congestion  and  pain;  second,  ease 
the  cough  and  aid  the  expectoration,  first  by  increasing  its 
fluidity,  and  later,  the  facility  of  expectoration. 

Some  general  sweating  measure  is  indicated  during  the  first 
stage  of  a  cold.  The  treatment  already  mentioned  in  the 
introduction  is  indicated  at  this  time.  Fomentations  to  the 
chest  and  throat  should  be  repeated  at  intervals  of  three  to  five 
hours  followed  by  the  heating  compress  to  the  throat  or  chest, 
according  to  the  location  of  the  congestion.  Fomentations  also 
relieve  the  excessive  cough  and  pain  accompanying  the  cough. 
The  drinking  of  hot  water  aids  diaphoresis  and  helps  to  increase 
the  fluidity  of  the  secretion  by  increasing  the  amount  of  water 
in  the  blood.  From  the  beginning  of  the  cold,  the  patient 
should,  after  every  hot  treatment,  be  given  a  cold  mitten  friction 
or  cold  towel  rub;  and  later,  such  treatment  as  hot  and  cold  to 
the  spine,  revulsive  compress  to  the  chest,  hot  and  cold  foot 
bath,  in  order  to  equalize  the  circulation  and  promote  return  to 
the  normal  tone.  In  acute  coryza  (cold  in  the  head)  alternate 
hot  and  cold  to  the  head  may  be  used  from  the  start,  and 
repeated  several  times.  A  hot  foot  bath  should  be  given  at 
the  same  time. 

CROUP 

In  diphtheritic  croup,  we  are  less  frequently  called  upon  to 
treat  extreme  conditions  than  before  the  introduction  of  anti- 
toxine.  However,  in  this  disease  and  also  in  simple  and  spas- 
modic croup,  expectorant  effects  are  indicated.  In  the  latter 
conditions  the  child  should  be  given  some  sweating  treatment, 
such  as  a  hot  foot  bath  accompanied  by  hot  moist  applications 


SS4  EXPECTORANT  EFFECTS 

to  the  chest  and  neck.  This  should  be  continued  until  the 
harsh,  brassy  cough  gives  way  to  free  and  easier  expectoration . 
When  this  occurs  the  dyspnoea  and  cyanosis  will  be  relieved. 
The  inhalation  of  medicated  steam  is  a  great  aid  in  the  treat- 
ment. Special  inhalers  may  be  provided  (Figs.  57  and  58.},  or 
an  ordinary  tea-kettle  or  basin  may  be  utilized  for  the  production 
of  steam  which  may  be  conveyed  to  the  patient  by  means  of  an 
inhaling  funnel  or  mask.  The  drinking  of  some  hot  liquid  will 
increase  the  sweating  and  hasten  the  loosening  of  the  secretions. 


Fig.  57.     Inhaler  for  medicated  steam.     (Kellogg.) 

The  heating  compress  or  the  moist  chest  pack  should  be  applied 
after  the  fomentations  and  left  in  place  from  thirty  minutes  to 
two  or  three  hours.  The  child  usually  falls  into  an  easy  sleep 
following  such  treatment.  In  some  cases  it  may  be  necessary 
to  dispense  with  the  moist  inside  part  of  the  chest  pack,  using 
only  the  dry  pack. 

ASTHMA 

The  treatment  of  the  asthmatic  paroxysm  by  means  of  hydro- 
therapy  is  a  disappointment,  and  this  in  spite  of  the  fact  that  by 
a  more  or  less  prolonged  course  of  hydriatic,  dietetic,  and  cli- 
matic treatment,  very  severe  cases  of  asthma  of  long  standing 
are  almost  completely  cured.  Permanent  and  very  decided  re- 


CHRONIC  BRONCHITIS  335 

suits  are  obtained  in  cases  that  submit  to  treatment  for  a  suffi- 
cient length  of  time.  Hydriatic  applications,  however,  may  be 
made  to  assist  in  relieving-  the  patient  during-  the  paroxysm. 
Two  objects  are  to  be  attained, — the  lessening-  of  the  dyspnoea 
and  facilitating-  expectoration.  These  may  be  accomplished  by 
some  mild  sweating-  treatment,  fomentations  to  the  chest,  or  the 
inhaling-  of  medicated  steam.  As  soon  as  the  patient  breaks 
out  into  a  gentle  perspiration,  the  dyspnoea  begins  to  lessen. 


Pig.  58.    An  improved  croup  kettle.    (Dieffenbach.) 

CHRONIC  BRONCHITIS 

This  condition  is  treated  in  much  the  same  manner  as  any 
chronic  inflammation.  The  results  to  be  obtained  are:  First, 
relief  of  the  cough;  and  second,  lessening-  of  the  amount  of  ex- 
pectoration and  facilitating"  its  expulsion.  The  patient  should 
be  given  a  definite  program  of  treatment,  such,  for  example,  as 
the  following-;  Hot  foot  bath,  together  with  fomentations  to  the 
chest  and  the  cold  mitten  friction;  also  fomentations  or  revul- 
sive compress  to  the  abdomen,  revulsive  compress  to  the  chest, 
hot  and  cold  to  the  spine,  cold  towel  rub,  salt  glow.  It  is 
usually  best  to  have  the  patient  wear  some  form  of  a  dry  chest 
pack.  All  of  these  measures  stimulate  the  circulation,  reducing 


EXPECTORANT  EFFECTS 

the  venous  stasis  in  the  lungs,  and  promote  resolution.  The 
fact  that  the  circulation  in  the  lungs  is  more  rapid  tends  to  de- 
crease the  amount  of  the  secretion.  The  patient's  general  vital 
resistance  is  raised  by  such  a  course  of  treatment. 

The  digestion  requires  special  attention.  "  Stomach  cough  " 
is  not  a  bad  name  for  many  cases  of  chronic  bronchitis,  since 
the  indigestion,  auto-intoxication,  and  sluggish  condition  of  the 
liver  are  very  largely  accountable  for  the  excessive  secretions. 
If  the  patient  may  be  induced  to  give  up  all  complicated  dishes, 
desserts,  meats,  rich  and  highly  seasoned  foods,  and  limit  him- 
self to  a  very  simple  diet,  the  condition  will  yield  to  treatment 
much  more  readily.  The  same  is  true  of  bronchial  asthma.  So 
astonishing  are  the  results  obtained  in  both  these  diseases  by 
rigid  dietetic  regulation,  accompanied  by  general  tonic  treat- 
ment, that,  although  requiring  a  long  time  to  produce,  they 
seem  almost  miraculous. 


CHAPTER  XXIII 
DIAPHORETIC  AND  DIURETIC  EFFECTS 

IT  will  be  noticed  that  nearly  all  of  the  diseases  in  which  diapho- 
retic and  diuretic  effects  are  especially  indicated  and  where 
they  must  be  used  repeatedly,  are  intimately  associated  with,  or 
due  to,  defective  metabolism.  The  treatments  that  promote 
diaphoresis  and  diuresis  all  powerfully  affect  metabolism. 
Internal  tissue  changes  are  of  course  the  antecedents  of,  and 
are  manifest  by,  changes  in  excretion.  It  is  these  tissue 
changes  and  the  consequent  elimination  of  carbon  dioxide  and 
nitrogenous  wastes  that  are  of  so  much  importance.  For  this 
reason  we  have  devoted  one  chapter  to  a  consideration  of  the 
methods  and  principles  of  diaphoretic  and  diuretic  treatment 
and  followed  it  by  another  devoted  to  the  special  application  of 
these  principles  in  systemic  diseases  and  diseases  of  metabolism. 

DIAPHORETIC  EFFECTS 

There  are  a  large  variety  of  measures  which  induce  general 
perspiration.  Any  hot  application,  even  if  local,  may  induce 
perspiration  over  the  entire  body.  The  measures  to  be  selected 
as  most  efficient  in  treating  a  disease  depend  upon  the  causes  of 
and  conditions  in  that  disease. 

The  following  is  a  list  of  the  principal  diaphoretic  measures: — 

1.  Electric  light  bath  (general  or  local). 

2.  Sun  bath. 

3.  Turkish  bath. 

4.  Superheated  air  bath  (250°— 400°  F.). 

5.  Russian  bath  or  vapor  bath. 

6.  Full  hot  bath. 

7.  Hot  blanket  pack. 

22  (337) 


DIAPHORETIC  AND  DIURETIC  EFFECTS 

8.  Dry  pack. 

9.  Electro-thermal  pack. 

10.  Heating  wet  sheet  pack. 

11.  Hot  spray  or  douche. 

12.  Hot  leg-  or  foot  bath. 

13.  Hot  sitz  bath. 

14.  Fomentations  to  the  spine. 

15.  Hot  water  drinking. 

16.  Hot  enema. 

Each  measure  has  its  own  range  of  applicability  and  special 
adaptability  to  the  needs  of  the  individual  case.  The  more 
local  and  milder  measures  have  a  wide  range  of  usefulness. 
The  more  extreme  and  general  heating  treatments  have  certain 
contraindications  which  must  not  be  disregarded.  Tonic  cold 
applications  should  usually  follow  sweating  treatment.  The 
main  effects  of  diaphoretic  applications  are  as,  follows: — 

1.  Increase  perspiration  (water  chiefly). 

2.  Increase  catabolic  changes  (spoliative  or  reducing). 

3.  Increase    elimination    of    toxins    through    the    skin    and 
through  the  kidneys  indirectly  by  relieving  these  organs  when 
overworked  or  congested,  thus  making  more  efficient  the  work 
which  is  done.     In  health,  diaphoretic  measures  do  not  increase 
the  amount  of  urine  and  may  considerably  decrease  it,  but  in 
all  conditions  where  there  is  lessened  functional  activity  of  the 
kidneys,   diaphoretic  measures  tend   to  produce   diuresis   and 
hasten  the  elimination  of  toxins  through  that  channel. 

4.  Increase  the  activity  of  the  sebaceous  glands  and  skin  in 
general,  thus  improving  its  nutrition. 

5.  Relieve  internal  congestion. 

6.  Decrease  dropsical  effusions. 

7.  Prepare    the   patient   for    cold    treatment    by    promoting 
ability  to  react. 

There  are  a  large  number  of  conditions  in  which  diaphoretic- 
measures  are  indicated.  In  a  few  diseases  the  most  vigorous 
sweating  treatments  may  be  used  with  great  benefit.  Below  is 
given  a  list  of  diseases  and  morbid  conditions  which  require 
special  diaphoretic  treatment.  Very  vigorous  means  may  be 
used  in  all  but  the  first  three. 


DIURETIC  EFFECTS  339 

Indications  for  diaphoresis: — 

1.  Icterus. 

2.  Systemic  poisoning-  (toxemia). 

3.  Internal  congestions. 

4.  Secondary  syphilis. 

5.  Obesity. 

6.  Acute  rheumatic  fever. 

7.  Gouty  rheumatism. 

8.  Gout  (podagra). 

9.  Bright' s  disease,  acute  and  chronic. 

10.  Uremia. 

11.  Eclampsia. 

Contraindications  to  extreme  sudorific  measures. 

1.  Asthma. 

2.  Organic  heart  disease. 

3.  Emaciated  rheumatics  and  diabetics. 

4.  Sunstroke  and  heatstroke. 

5.  Pulmonary  tuberculosis. 

6.  Asthenic  fevers. 

7.  Icterus. 

8.  Emaciation  and  exhaustion. 

9.  Old  ag-e. 

DIURETIC  EFFECTS 

We  have  previously  shown  the  close  connection  existing 
between  the  functions  of  the  kidneys  and  skin  in  diseases  of 
either  of  these  organs.  Above  is  given  a  list  of  the  various 
sudorific  measures.  All  of  these  treatments  are  beneficial  in 
conditions  of  defective  kidney  activity.  It  has  long-  been 
known  that  nephritis  and  diseases  of  metabolism,  closely 
associated  with  the  functions  of  the  kidney,  are  benefited  by 
free  diaphoresis.  In  these  diseases  all  brisk  sudorific  measures 
indirectly  increase  urinary  secretion.  This  is  probably  due  to 
the  fact  that  renal  congestion  is  lessened,  the  stag-nation 
relieved,  so  that  while  there  is  less  blood  in  the  kidneys  at  any 
one  time,  the  rapidity  of  the  renal  circulation  is  increased.  The 
secretion  of  urine  is  therefore  more  efficient  and  the  quantity  of 
the  watery  and  solid  constituents  is  increased.  The  increase  in 


S40  DIAPHORETIC  AND  DIURETIC  EFFECTS 

urinary  solids  is  due  not  alone  to  stimulation  of  the  renal 
epithelium  by  a  quickened  circulation,  but  also  to  heightened 
metabolic  changes  occurring-  in  the  tissues  themselves.  The 
stimulation  of  the  general  circulation  and  especially  of  the 
hepatic  circulation  and  of  the  liver  cells,  produced  by  sweating 
treatment  or  accompanying  the  reaction  to  cold  treatment,  has 
been  shown  to  increase  the  toxicolytic  powers  of  the  liver. 
Toxemia  is  thus  lessened  in  a  very  direct  manner.  The  blood 
being  less  toxic,  irritation  of  the  renal  cells  is  decreased  and 
the  work  done  by  the  kidney  is  more  efficient. 

The  following  are  the  principal  diuretic  measures  which  are 
useful  in  kidney  insufficiency  and  allied  conditions: — 

1.  Full  blanket  pack. 

2.  Electric  light  bath. 

3.  Russian  and  other  vapor  baths. 

4.  Hot  air  baths. 

5.  Full  warm  tub  bath. 

6.  Water  drinking  (especially  with  above). 

7.  Cold    (or  hot  and  cold)    douche   to   lower   sternum  and 
lumbar  spine  (entire  width  of  back) . 

8.  Cold  heating  trunk  pack  or  the  rubbing  wet  sheet  pack. 

9.  Fomentations  to  lumbar  spine. 

10.  Intermittent  or  continuous  proctoclysis  with  warm  physio- 
logic salt  solution. 
Indications: — 

1.  Bright 's  disease,  acute  or  chronic. 

2.  Uremia,  eclampsia,  and  other  toxemias. 

3.  Acute  suppression  of  the  urine. 

4.  Ether  and  post-operative  nephritis. 

5.  Ptomaine  poisoning. 

6.  Poisoning  by  lead,  turpentine,  alcohol,  etc. 


CHAPTER   XXIV 

SYSTEMIC  AND  METABOLIC  DISEASES 
OBESITY 

IN  considering-  the  effects  of  thermic  applications  upon  tissue 
changes  in  respect  to  both  nitrogenous  and  carbonaceous 
metabolism,  it  was  shown  that  all  forms  of  cold  treatment 
increase  catabolic  changes,  also  that  excessive  heat  or  long  con- 
tinued heat  has  the  same  effect.  The  two  extremes,  however, 
do  not  have  the  same  effect  upon  anabolism,  heat  having  little 
or  no  tendency  to  increase  the  building-up  processes  through 
increased  absorption  and  assimilation  of  food.  Tonic  cold 
applications  often  increase  anabolism  more  than  catabolism. 
It  is  for  this  reason  that  cold  applications  signally  fail  in  secur- 
ing any  great  reduction  in  weight.  The  patient  may  lose  a  few 
pounds. 

Of  course,  the  general  vitality  of  the  patient  and  all  nutritive 
processes  are  enhanced  by  alternating  hot  and  cold  applications. 
This  is  doubtless  the  more  rational  way  to  treat  obesity,  since 
it  is  more  necessary  to  improve  the  general  condition  of  the 
patient  than  to  reduce  the  weight;  but  if  the  reduction  of  the 
weight  is  the  objective  point,  it  is  necessary  to  resort  to 
extreme  sudorific  measures,  unaccompanied  by  cold  applica- 
tions. For  this  reason  it  is  not  possible  to  greatly  reduce  the 
weight  of  persons  suffering  from  fatty  heart,  accompanying  the 
•general  obesity.  Spoliative  and  reducing  measures  aim  at 
increasing  catabolism  without  a  corresponding  increase  in 
anabolism.  All  extreme  sudorific  measures  available  should  be 
used  in  this  condition.  Those  which  will  be  found  most  helpful 
are  the  Russian  bath,  Turkish  bath,  electric  light  bath,  full 
blanket  pack,  electro-thermal  pack,  and  sweating  wet  sheet 

(341) 


Slfl  SYSTEMIC  AND  METABOLIC  DISEASES 

pack.  The  full  hot  bath  and  the  mud  baths  commonly  used  at 
hot  spring's  may  be  used.  These  do  not,  however,  have  any 
advantage  over  the  first  three  measures  mentioned. 

The  patient  should  have  one  prolonged  sweating  treatment 
daily.  It  is  often  necessary  to  finish  with  a  very  short  cold 
spray.  This  should  not  be  greatly  prolonged  for  the  reasons 
above  mentioned.  The  patient  should  take  as  much  vigorous 
exercise  as  possible.  Heavy  massage  may  also  be  used.  It  is 
needless  to  say  that  the  following'  of  such  a  program  will  result 
in  weakening-  the  patient,  as  well  as  in  reducing  the  weight. 
These  measures  will  all  fail  unless  the  diet  is  reduced,  especially 
as  regards  the  total  number  of  calories.  As  soon  as  the  patient 
returns  to  his  usual  habits  of  inactivity  and  over-feeding,  there 
will  be  a  prompt  gain  in  weight  which  will  replace  all  that  has 
been  lost.  Extreme  sweating-  treatments  do,  however,  materi- 
ally reduce  the  weight  and,  by  guarding  the  diet  and  encourag- 
ing exercise,  the  loss  in  weig-ht  may  be  quite  permanent. 

ICTERUS 

It  is  usually  impossible  to  employ  prolonged  or  extreme  dia- 
phoretic treatment  in  this  condition,  but  free  perspiration 
should  be  encouraged,  since  by  increasing-  the  elimination  of 
bile  through  the  sweat,  it  relieves  the  nervous  irritability  and 
aids  in  relieving  pruritus.  Local  hot  applications  are  illy  borne 
because  of  the  extreme  sensitiveness  of  the  skin.  The  electric 
light  bath  is  a  very  efficient  means,  since  its  heat  is  evenly  dis- 
tributed. The  drinking  of  much  water  is  an  essential  for  both 
free  diaphoresis  and  diuresis. 

SYSTEMIC  POISONING 

In  many  conditions  in  which  toxic  substances  circulate  in  the 
blood  and  lymph,  free  diaphoresis  materially  hastens  their 
elimination.  Such  substances  may  be  produced  by  auto-intoxi-. 
cation  from  intestinal  sources,  or  faulty  metabolism.  General 
poisoning  may  result  from  the  ing-estion  of  ptomaines,  lead, 
mercury,  alcohol,  etc.  In  some  cases,  vigorous  diaphoresis  is 
necessary;  in  others,  only  mild  diaphoresis  with  copious  water 
drinking-  should  be  used.  Because  of  the  weakness  and  debility 


GOU'l  343 

resulting-  from  the  poison,  extreme  sweating-  measures  can  not 
be  used.  A  short  electric  light  bath  is  often  all  that  is  neces- 
sary. Renal  elimination  should  be  hastened  by  free  water 
drinking". 

INTERNAL  CONGESTIONS 

The  use  of  sudorific  measures  in  relieving-  congestion  of  the 
viscera  has  been  considered  elsewhere,  especially  in  connection 
with  inflammations  and  diseases  of  the  kidneys.  It  is  not  pos- 
sible for  an  extreme  congestion  to  exist  in  the  internal  organs 
while  the  skin  is  red  and  congested,  as  occurs  in  a  sweating 
treatment.  But  in  order  to  more  permanently  relieve  the 
internal  congestion, -it  is  necessary  that  the  blood  be  retained 
in  the  skin.  This  is  not  accomplished  by  the  hot  alone,  but 
can  be  by  the  reaction  hyperemia  resulting  from  a  cold  friction. 
The  principle  of  these  effects  has  been  considered  in  connection 
with  the  subjects  of  derivation  and  fluxion.  The  relief  of 
visceral  congestions  by  general  sudorific  measures  is  indicated 
in  acute  nephritis,  eclampsia,  uremia,  pulmonary  congestion, 
acute  pleurisy,  and  the  early  stages  of  many  infectious  diseases 
such  as  influenza,  measles,  scarlet  fever,  etc. 

GOUT  AND  GOUTY  RHEUMATISM 
General  Consideration 

The  literature  on  the  purin  diathesis  is  most  voluminous  and 
much  of  it  unreliable;  there  are,  however,  some  important  facts 
regarding  purin  metabolism  that  have  been  sufficiently  well 
proven  to  allow  of  their  being  used  as  a  foundation  for  the 
basic  principles  involved  in  the  treatment  of  these  conditions. 
We  can  not  here  attempt  anything  like  a  complete  consideration 
of  this  question,  but  merely  point  out  those  facts  which  seem  to 
us  to  be  of  importance  in  determining  the  treatment.  There 
seem  to  be  three  causes  for  the  accumulation  of  basic  purins 
and  uric  acid  in  the  system.  These  are:  First,  excessive 
ingestion  of  purin-containing  foods  over  long  periods  of  time; 
second,  defective  and  deficient  xanthin  oxidation  and  uricolysis; 
and  third,  decreased  elimination  of  purins  because  of  kidney 
insufficiency. 


SU  SYSTEMIC  AND  METABOLIC  DISEASES 

To  provide  a  diet  free  from  purin  is  not  difficult,  and  so  the 
removal  of  this  first  cause  is  a  comparatively  easy  matter.  To 
remedy  the  second  is,  however,  a  more  difficult  matter.  It  has 
been  shown  how  applications  of  both  heat  and  cold  accomplish 
a  quite  thorough  xanthin  oxidation,  /.  e. ,  a  change  of  the  basic 
purins  to  uric  acid.  This  change  of  basic  purins  to  uric  acid  is 
a  distinct  advantage,  as  uric  acid  is  less  irritating  to  the  renal 
epithelium  than  the  bases.  "  Mammals  form  uric  acid  only 
from  the  purins  and  have  the  power  of  destroying  some  of  the 
uric  acid  formed.  This  uricolytic  power  is  relatively  weak  in 
man."1 

Nucleoproteids  are  converted  into  free  purins  and  these,  in 
turn,  are  changed  into  uric  acid  by  the  loss  of  nitrogen  and  the 
addition  of  oxygen.  "  "  Wiechowski  has  particularly  studied  the 
enzyme  concerned  in  the  destruction  of  uric  acid  by  the  tissues , 
and  the  fate  of  free  uric  acid  in  the  body.  This  uricolytic 
enzyme,  which  has  been  appropriately  called  uricase  by  Batteli 
and  Stern,  is  an  oxidizing  enzyme,  acting  best  in  experimental 
digestions  when  a  lively  current  of  air  is  running  through  the 
digestion  mixture,  and  which  seems  not  to  be  present  in  the 
blood  plasma  and  tissue  fluids,  but  only  in  the  cells.  It  acts 
rapidly  and  with  striking  effect,  for  active  organ  extracts  are 
sometimes  able  to  destroy  quite  considerable  quantities  of  uric 
acid  in  a  few  hours;  for  example,  one  gram  of  powdered  tissue, 
dry  weight,  can  often  destroy  totally  0.1  gram  of  uric  acid  in 
four  hours.  Unlike  the  enzymes  of  autolytic  disintegration  of 
tissues,  uricase  is  not  inhibited  by  the  presence  of  an  excess  of 
serum.  Another  interesting  feature  is  that  this  enzyme  acts 
reversibly,  or  at  least  tissue  extracts  which  destroy  uric  acid 
with  a  current  of  air  running  through,  soon  build  up  the  uric 
acid  again  when  the  air  is  shut  off."* 

The  above  facts  show  the  benefit  to  be  derived  from  hydro- 
therapy  in  stimulating  the  circulation,  increasing  the  oxygen- 
carrying  capacity  of  the  red  cells,  and  increasing  oxidation  in 
the  body  tissues.  Out-of-door  life  in  the  fresh  air  and  sleeping 

1  H.  G.  Wells— Trans.  Chicago  Pathological  Society,  May  1,  1909. 

2  Editorial   in  Journal  of  American   Medical   Association.   October  9,    1909,  p.  1191: 
see  also  The  Oxidases.  Bulletin  No.  59,  p.  103.  of  Hygienic  Laboratory,  Public  Health 
and  Marine  Hospital  Service  of  the  United  States 


GOUT  345 

out  of  doors  furnishes  the  abundant  supply  of  oxygen  so  neces- 
sary to  uricolysis. 

In  addition  to  the  effects  of  hydrotherapy,  certain  articles  of 
diet  play  an  important  part  in  the  prevention  of  uricacidemia. 
This  is  notably  so  of  fruit.  "  Weis,  in  1898,  asserted  that  after 
eating-  fruit  the  uric  acid  of  the  urine  is  decreased  and  the 
hippuric  acid  increased."  "  Wohler  found  uric  acid,  but  no 
hippuric  acid,  in  the  urine  of  sucking-  calves,  so  long  as  they 
consumed  nothing  but  milk.  But  as  soon  as  they  passed  on  to 
vegetable  food,  the  uric  acid  disappeared  and  hippuric  acid 
was  substituted.  It  thus  appears  that  the  benzoic  acid  arising 
from  vegetable  diet  siezes  upon  the  glycocol  and  prevents  the 
synthesis  of  uric  acid. 

"it  is  useless  merely  to  give  benzoate  of  sodium,  as  I  have 
proved  by  many  experiments.  But  here  again  it  should  not  be 
forgotten  that  it  is  not  in  our  power  to  make  the  benzoic  acid 
reach  the  proper  point  at  the  proper  moment  when  the  glycocol, 
before  its  union  with  the  cyanic  acid  could  reach  it.  As 
already  mentioned,  the  benzoic  acid  in  vegetable  food  is  not 
generally  contained  as  such,  but  is  formed  in  the  body  by  the 
decomposition  and  oxidation  of  more  complex  combinations. 
It  is  quite  possible  that  these  latter  are  taken  up  by  the  cells  in 
which  glycocol  occurs,  while  the  benzoic  acid  already  formed  is 
rejected."4 

The  use  of  medicinal  substances  in  the  treatment  of  gout, 
outside  of  those  found  in  man's  natural  diet  is  a  disappoint- 
ment. This  is  true  of  benzoic  acid,  the  salicylates  and  also  of 
lithium.  This  latter  neither  affects  the  solubility  of  uric  acid 
in  the  tissues  nor  in  the  slightest  increases  its  elimination  by 
the  kidneys. 

Even  if  lithium  exerted  an  influence  on  the  solubility  of  uric 
acid,  the  amounts  present  in  commercial  lithia  waters  would  be 
too  minute  to  accomplish  anything.  Relative  to  this  fact,  Dr. 
Henry  Leffmann  says, —  ° 


3  Lewellys  F.  Barker— Truth  and  Poetry  Concerning:  Uric  Acid,  p.   32. 

4  Bunge— Physiological  and  Pathological   Chemistry,   Second  English   Edition,  pp. 
303,  304. 

5  Proceedings    of   the    Philadelphia   County    Medical    Society.    December    8,    1909, 
reported  in  Journal  of  American  Medical  Association  of  February  19.  1910. 


S46  SYSTEMIC  AND  METABOLIC  DISEASES 

' '  On  the  result  of  an  analysis  of  about  two  score  of  the  so- 
called  mineral  waters,  the  Bureau  of  Chemistry  of  the  Depart- 
ment of  Agriculture  has  recently  issued  a  circular  of  inquiry, 
the  essential  features  of  which  I  give  herewith.  It  has  been 
found  that  nearly  all  '  lithia  waters  '  either  contain  only  spectro- 
scopic  traces  of  lithium  (unweighable  quantities  in  from  2  to  4 
liters),  or  contain  less  than  one  part  per  million  (approximately 
0.05  grain  per  gallon)  of  lithium." 

Along  the  same  line  we  quote6  the  following  from  Bunge: — 
"  If  it  be  desired  to  prevent  the  formation  of  uric  acid  sedi- 
ments, or  to  dissolve  concretions  that  are  already  formed,  by  the 
administration  of  alkalies,  it  is  more  sensible  to  advise  the  use 
of  fruits  and  potatoes  than  to  order  alkaline  mineral  waters,  the 
continued  use  of  which  may  produce  disturbances  which  we  are 
unable  to  estimate.  Because  the  combination  of  uric  acid  and 
lithia  is  more  soluble  in  water  than  its  combination  with  soda 
or  potash,  it  has  been  thought  necessary  to  treat  the  uric  acid 
diathesis  with  a  few  decigrammes  of  carbonate  of  lithia,  or  even 
with  mineral  waters  containing  one  centigram  of  lithia  to  the 
liter.  This  naive  idea  simply  implies  ignorance  of  Berthollet's 
law.  We  know  that  in  solutions  of  bases  and  acids,  every  acid 
is  distributed  to  all  the  bases  in  proportion  to  their  quantity. 
It  follows  that  only  the  very  smallest  portion  of  uric  acid  will 
combine  with  the  lithia,  the  largest  proportion  combining  with 
the  preponderating  quantity  of  soda,  which  we  introduce  as 
chloride  of  sodium.  The  largest  proportion  of  lithia  will 
reappear  in  the  urine,  united  with  the  chlorine  of  the  chloride, 
with  sulphuric  and  phosphoric  acid.  There  will  be  no  increase 
in  the  solubility  of  uric  acid." 

Treatment 

Purin  diathesis,  true  gout,  and  allied  conditions,  such  as  the 
myalgias,  lumbago,  the  visceral  forms  of  gout,  etc.,  are  usually 
treated  by  extreme  diaphoretic  measures.  It  must  be  confessed, 
however,  that  the  majority  of  rheumatics  are  not  able  to  stand 
such  treatment.  Only  those  who  are  obese  or  of  more  than 
average  weight  can  stand  extreme  sweating  measures.  It  is 

6    Physiological  and  Pathological  Chemistry,  Second  English  Edition,  p.    322. 


RHEUMATISM  347 

for  these  reasons  that  many  a  rheumatic  patient  leaves  a  course 
of  baths  at  the  hot  springs  in  worse  condition  than  when  he 
began.  Many  and  many  are  the  patients  that  year  after  year 
visit  the  various  spas  of  this  country  and  Europe,  deriving 
each  time  only  a  temporary  benefit.  For  this,  there  are  two 
reasons:  All  are  given  the  same  routine  of  hot  baths,  regard- 
less of  the  individual  conditions  and  needs.  Obese  or  ema- 
ciated, they  are  all  treated  alike.  Second,  there  is  a  failure  to 
eliminate  from  the  diet  all  purin-containing  foods  and  reduce  to 
a  minimum  the  proteid  intake.  Chittenden  has  shown  that  a 
daily  ration  containing  35  to  60  grams  of  proteid  is  not  only 
compatible  with  perfect  health,  but  also  conducive  to  gain  in 
muscular  capacity,  increasing  the  endurance  to  prolonged  mus- 
cular effort  and  lessening  fatigue.  In  gout  and  gouty  rheuma- 
tism the  proteid  should  be  reduced  to  the  least  amount  com- 
patible with  the  actual  need  of  the  body  for  nitrogen.  As 
pointed  out  by  Garrod,  every  particle  of  food  not  absolutely 
needed  for  the  nourishment  of  the  body  merely  nourishes  the 
disease.  One  can  not  hope  to  cure  disease  unless  the  cause  is 
removed.  In  the  purin  diathesis,  the  two  chief  causes  are  over- 
feeding and  under  exercise.  The  over-feeding  is  in  the  line  of 
heavily  proteid  foods  and  foods  containing  purin.  These  must 
be  eliminated  from  the  diet,  if  great  benefit  is  to  be  derived  from 
treatment . 

For  practical  purposes,  we  must  divide  gouty  jheumatism  into 
two  classes,  viz.,  obese  rheumatics  and  emaciated,  anemic 
rheumatics.  In  the  first  class,  sweating  treatment  maybe  used 
with  benefit  when  properly  combined  with  tonic  measures.  In 
the  second  class,  extreme  sweating  treatment  is  not  permissible. 

Rheumatism  with  Obesity.  Those  patients  who  are  well 
nourished  may  be  given  a  thorough  sweating  treatment  daily. 
Any  of  the  sudorific  measures  recommended  in  obesity  are 
serviceable.  The  Turkish  bath,  Russian  bath,  electric  light 
bath,  full  superheated  dry  air  bath,  hot  blanket  pack,  sweating 
wet  sheet  pack,  or  electro-thermal  pack,  are  all  applicable. 
Their  effects  may  be  greatly  enhanced  by  free  water  drinking. 
The  mineral  waters  possess  no  advantage  over  any  pure  water. 
The  beneficial  results  are  derived  from  the  free  perspiration 


348  SYSTEMIC  AND  METABOLIC  DISEASES 

and  diuresis  it  induces.  It  thus  affords  ample  solvent  for  the 
increased  nitrogen  excretion.  F.  Umber7  claims  that  alkaline 
water  has  the  opposite  effect;  also  that  the  blood  of  grouty 
patients  is  able  to  dissolve  larger  proportions  of  free  uric  acid 
than  it  ever  contains.  He  declares  that  none  of  the  alkalies  or 
mineral  waters  have  any  specific  influence  on  the  purin  met- 
abolism in  grout  and  that  the  propaganda  for  the  "lithium  con- 
tent," etc.,  of  spring's  should  be  abandoned. 

Tonic  measures  should  not  be  neglected.  The  strength 
should  be  maintained  and  the  circulation  stimulated.  All  hot 
baths  should  be  followed  by  some  form  of  cold  treatment. 
These  may  at  first  have  to  be  mild,  but  obese  patients  stand 
cold  treatment  well.  The  alternate  hot  and  cold  percussion 
douche  is  an  excellent  means.  It  serves  as  a  massage,  stimu- 
lates the  vasomotors,  and  restores  the  tone  lost  because  of  the 
hot  bath.  It  should  be  applied  especially  to  the  spine  and  legs 
and  should  consist  of  from  three  to  five  complete  changes  from 
hot  to  cold.  The  patient  should  be  dried  from  the  cold  and 
may  either  rest  or  take  exercise  after  it,  according  to  the  con- 
ditions of  the  particular  case  under  observation.  Individualiza- 
tion  is  the  life  of  therapy  no  less  with  rheumatism  than  with 
other  diseases.  Light  or  heavy  massage  may  be  given.  The 
massage  douche  is  highly  recommended  by  some.  It  possibly 
possesses  some  advantage  over  the  percussion  douche.  The 
Turkish  shampoo  is  an  excellent  means  of  combining  massage 
with  vigorous  sudorific  measures.  Other  tonic  applications 
may  be  used,  such  as  cold  affusions  and  general  sprays  and 
showers.  Later  in  the  disease,  the  wet  sheet  rub  may  be  used 
to  advantage. 

Rheumatism  with  Emaciation.  This  condition  is  doubtless 
in -some  cases  the  direct  result  of  "hot  springs"  treatment. 
Hot  treatment  must  be  used  with  much  caution.  The  vigorous 
sweating  treatments  are  never  to  be  employed  if  the  patient  is 
under  weight.  Local  hot  applications  are  permissible  and  a 
mild  sweating  treatment  once  a  week  may  in  some  cases  be 
ventured  upon.  Hot  applications  to  the  swollen  joints,  as  fomen- 
tations,  local  hot  air  baths,  superheated  air  (Plates  XV  and 

7    Therapie  der  Gegenwart.  February.  L,  No.  2..  pp.  73—120. 


PLATE  XV.     Superheated  dry  air  bath.     Foot  bandaged  in  Turkish  toweling 
ready  to  be  introduced. 


PLATE  XVI.     .Superheated  dry  air  bath.     Treating  foot. 


RHEUMATISM  3Jf9 

,  or  local  electric  light  bath  should  be  followed  by  a  tonic 
friction.  At  first  this  may  be  a  wet  hand  rub  with  tepid  water, 
then  with  cold  water  and  later,  the  cold  mitten  friction.  These 
frictions  should  be  applied  to  the  muscular  portions  of  the  body, 
the  swollen  joints  being  avoided.  The  joints  should  be  envel- 
oped in  heating  compresses  or  packs  wrung  from  cold  water. 
These  should  be  thoroughly  covered  with  several  layers  of 
flannel  or  absorbent  cotton,  if  necessary,  in  order  to  exclude 
the  air.  The  effect  may  be  increased  by  counter-irritants  or 
anodynes.  After  a  time  the  alternate  soft  spray  douche*  may 
be  applied  to  the  joints  and  the  body  generally.  When  conva- 
lescence is  well  established,  the  patient  should  be  given  daily 
some  general  tonic  treatment  with  only  short  preliminary  hot 
applications. 

In  true  gout,  z.  e.,  where  the  disease  is  localized  in  the 
metatarso-phalangeal  joint  of  the  great  toe,  the  tonic  measures 
outlined  for  gouty  rheumatism  must  be  used  in  the  interval. 
Only  hot  applications  can  be  made  to  the  foot  during  the  par- 
oxysm. 

At  first  the  patient  suffering  from  rheumatism  will  complain 
some  of  increased  stiffness  and  possibly  pain  in  the  joints  after 
even  a  mild  cold  friction.  This  should  not  deter  the  physician 
from  following  the  plan  outlined  nor  cause  discouragement  on 
the  part  of  the  patient.  If  much  complaint  is  made,  the  alcohol 
rub  may  for  a  time  be  substituted. 

Faradization  of  the  joints  by  the  rapid  faradic  current  helps 
to  relieve  the  pain  and  the  annoying  paresthesias  that  keep  the 
patient  awake.  Gentle  massage  of  the  muscles  and  rubbing  to 
the  spine  are  helps  in  treating  the  insomnia.  The  myalgias 
such  as  lumbago  may  be  treated  as  recommended  elsewhere. 
In  lumbago,  however,  the  most  vigorous  hot  and  cold  percus- 
sion douche  to  the  back  should  be  used,  followed  by  heavy 
massage  or  firm  deep  vibration  to  the  large  muscles  of  the 
back.  These  relieve  the  pain  as  milder  measures  will  not. 

In  some  cases  of  rheumatism,  notably  where  the  patient  is 
bed-ridden  or  must  be  closely  confined  to  the  wheel  chair,  it  is 
best  to  follow  a  somewhat  different  plan  than  that  outlined 
above.  In  these  cases,  only  mildly  hot  local  applications,  such 


S50  SYSTEMIC  AND  METABOLIC  DISEASES 

as  the  fomentation,  radiant  heat,  and  the  hot  foot  bath  should 
be  used.  The  usual  regime  of  cold  treatment  should  be 
omitted  and  its  place  taken  by  carefully  applied  but  thorough 
massage.  This  massage  should  include  special  attention  to 
nerve  stimulation,  spinal  and  abdominal  movements.  The  use 
of  faradic  and  sinusoidal  electricity  for  the  same  purpose  is  an 
addition  of  distinct  advantage. 

In  all  cases  of  chronic  rheumatism,  special  attention  must  be 
given  to  the  alimentary  tract  and  to  the  digestion.  Modern 
investigations  into  the  contributing  causes  of  chronic  articular 
rheumatism  are  turning  more  and  more  to  alimentary  stasis, 
intestinal  infections,  and  auto-intoxications  for  an  explanation  of 
the  pathogenesis  of  metabolic  forms  of  chronic  articular  rheu- 
matism. In  some  of  these  cases  the  purin  diathesis  doubtless 
has  nothing  to  do  with  the  disease  or  at  most  plays  only  a 
minor  part.  The  routine  use  of  gastric  lavage  and  copious 
enemata  for  a  limited  time  may  be  productive  of  excellent 
results.  These  treatments  must  be  thorough  to  be  effective. 
Purin  accumulation  through  defective  xanthin  oxidation  and 
very  limited  uricolysis  are  a  part  of  this  auto-intoxication,  and 
are  surely  to  be  traced  to  an  overworked  and  functionally 
deranged  liver  as  one  source  of  their  occurrence. 

BRIGHT'S  DISEASE 

Diaphoretic  measures  are  valuable  in  both  acute  nephritis 
and  in  the  various  clinical  and  pathological  varieties  of  chronic 
nephritis.  It  is  hardly  necessary  for  our  purpose  to  discuss  the 
structural  alterations  occurring  in  the  kidneys  in  Bright 's 
disease.  Only  in  acute  nephritis  is  there  hope  of  any  marked 
restoration  of  the  normal  structure.  However,  the  functional 
perversions  may  to  a  great  extent  be  corrected.  The  alteration 
.of  function  which  is  the  chief,  if  not  the  sole  cause  of  the 
various  clinical  manifestations  of  nephritis,  is  the  renal  imper- 
meability and  insufficiency  in  the  elimination  of  nitrogenous 
wastes  and  salines.  There  is  also  an  abnormal  permeability  to 
albumen  and,  in  some  cases,  to  water,  notably  so  in  the  inter- 
stitial variety  of  chronic  nephritis. 

In  interstitial  nephritis  and  the  kidney  of   arterio-sclerosis, 


BRIGHT S  DISEASE  351 

the  high  blood  pressure  is  a  prominent  symptom  and  is  due,  at 
least  to  a  great  extent,  to  nitrogenous  toxins.  "Experiments 
on  patients  with  chronic  nephritis  have  shown  that  rich  protein 
diet  increases  tension  and  disturbs  the  general  condition  of  the 
patient  for  the  worse.  Miiller  describes  an  individual  in  whom 
a  change  from  milk  and  carbohydrate  diet  to  rich  meat  diet 
caiised  pressure  to  rise  from  140  to  190.  Rich  meat  diet  causes, 
in  nephritics,  headache,  one  of  the  earliest  and  most  constant 
symptoms  of  uremia,  and  one  which  has  a  definite  relation  to 
hypertension." 

Treatment  must,  therefore,  be  directed  toward  the  attaining 
of  two  objects:  First,  decreasing  the  amount  of  toxic  sub- 
stances and  salines  the  kidneys  are  required  to -excrete; 
second,  increasing  renal  sufficiency,  so  shaping  conditions  that 
increased  elimination  may  occur  without  increased  strain  and 
irritation  of  the  kidneys.  In  order  to  meet  the  first  indication, 
it  is  necessary  to  bring  about  several  changes.  The  ingestion 
of  purins  (exogenous)  must  be  stopped.  The  consumption  of 
proteids  must  be  limited  as  far  as  the  needs  of  the  system  will 
allow.  By  general  hygiene,  exercise,  etc.,  one  may  decrease 
the  formation  of  intestinal  toxins  and  promote  complete  oxida- 
tion of  nitrogenous  wastes.  These  results  may  be  attained  by 
regulation  of  the  diet  and  attention  to  digestion.  For  a  time  it 
is  well  also  to  limit  the  use  of  salt  to  what  naturally  occurs  in 
the  food. 

The  experiments  of  Strasser  prove  conclusively  that  the 
second  object,  viz. ,  increasing  the  elimination  of  nitrogen, 
salines,  and  water,  is  best  accomplished  by  the  systematic  use  of 
hydro  therapy;  and  that  what  has  been  vainly  hoped  from 
diuretic  drugs  is  produced  by  bathing.  His  experiments  were 
largely  with  the  full  warm  bath  at  95° — 100°  F.  In  all  cases 
there  was  a  decided  increase  in  the  quantity  of  urine  and 
chlorides  excreted,  which  frequently  continued  several  days 
after  the  cessation  of  treatment.  In  no  case  was  there  a  storage 
of  nitrogen  or  salines  on  the  bath  days.  This  was  true  alike  of 
cases  having  edema  and  where  there  was  no  decrease  in  the 


8    J.  H.  Musser — Causes  of  Hypertension  in  Nephritis— Journal  of  American  Medical 
Association,  November  27,  1909,  p.  1791. 


352  SYSTEMIC  AND  METABOLIC  DISEASES 

chlorides  or  nitrogen  in  the  diet.  The  full  warm  bath  fre- 
quently increased  the  elimination  of  sodium  chloride  two  or 
three  times  the  usual  amount.  In  one  case,  increase  in  the 
nitrogen  and  sodium  chloride  of  the  urine  occurred  without 
increase  in  the  total  amount  of  urine  and  continued  for  three 
days  after  the  treatment. 

Relative  to  the  relation  of  the  two  crystalloids — glucose  and 
sodium  chloride — to  dropsy  and  diuresis,  some  interesting 
facts  have  been  pointed  out  by  Starling.  While  the  presence 
of  unusual  amounts  of  glucose  in  the  circulating  fluid  induces 
diuresis  at  the  expense  of  tissue  fluids,  the  ingestion  of  much 
salt  does,  under  certain  circumstances,  tend  to  increase  tissue 
fluids  and  limit  diuresis,  producing  a  ' '  water-logged  ' '  condition. 

"  If  a  solution  of  30  grains  of  glucose  in  about  30  cubic  centi- 
meters of  water  be  injected  into  the  jugular  vein,  the  first  effect 
is  a  great  increase  in  the  volume  of  the  circulating  blood, 
brought  about  by  the  osmotic  attraction  of  water  into  the  vessels 
at  the  expense,  first,  of  the  tissue  spaces,  but  ultimately  of  the 
tissue  cells.  The  consequence  of  the  hydremic  plethora  there- 
by induced  is  increased  circulation  through  the  kidneys  and 
increased  output  of  urine  containing  large  quantities  of  sugar. 
.  .  .  Under  ordinary  circumstances,  the  concentration  of  the 
tissues  thus  induced  would  produce  intense  thirst  and  an  in- 
creased intake  of  water,  so  that  the  urinary  flow  would  be  main- 
tained at  a  high  level  until  the  whole  excess  of  the  glucose  had 
been  excreted." 

'  The  ingestion  of  an  excessive  quantity  of  salt  provokes 
thirst  rather  than  diuresis.  If  this  excessive  ingestion  were 
continued  or  became  chronic,  there  would  be  a  tendency  for 
the  amount  of  this  salt  in  the  body  to  continually  increase, 
the  salt  being  associated  with  sufficient  water  to  maintain  the 
molecular  concentration  of  the  body  fluids  at  their  normal 
height.  It  is  not  surprising,  therefore,  that  excessive  quanti- 
ties of  salt  have  been  found  to  exert  a  deleterious  influence  in 
cases  of  dropsy,  or  that  marked  benefits  as  regards  the  reduc- 
tion of  dropsy  have  been  attaided  by  the  limitation  of  salt  in  the 
diet."10 

9  Starling— Fluids  of  the  Body.  p.  153. 
10  Ibid.,  p.  154. 


NEPHRITIS  353 

Edema  is  lessened  by  warm  or  sweating-  baths  and  sometimes 
very  promptly.  The  dropsy  responds  even  more  promptly  to 
alternate  hot  and  cold  applications  to  the  edematous  parts. 
The  rationale  of  these  hydriatic  effects  in  lessening  edema  is  a 
very  interesting-  study.  We  have  already  dwelt  quite  at  length 
upon  the  vascular  changes  produced  by  alternating-  thermic 
applications .  Starling-  has  recently  correlated  present  knowledge 
regarding  the  causation  of  dropsy.  In  the  summary  he  brings 
out  a  number  of  practical  points.  "  Ranvier  has  shown  that  if, 
after  ligature  of  the  inferior  vena  cava,  the  sciatic  nerve  be 
divided  on  one  side  so  as  to  produce  dilatation  of  the  arterioles 
on  that  side,  the  limb  in  which  the  nerve  has  been  divided  will 
become  edematous."  There  must  be  other  factors  beside 
venous  obstruction  if  edema  is  to  result.  Starling-  concludes 
that  the  determining  cause,  other  than  stasis,  lies  in  an  in- 
creased permeability  of  the  vessel  wall.  This  is  due  in  dis- 
ease to  lack  of  the  proper  nutrition  and  oxygen  supply  to  the 
cells  of  the  vessel  wall.  "  Cohnheim  showed  that,  after  long 
continued  anemia  of  the  rabbit's  ear,  the  vessels  became  so  per- 
meable that  restoration  of  the  normal  circulation  was  followed 
by  pronounced  edema  of  all  the  tissues."  ^ 

The  same  results  were  obtained  by  Barlow.  This  anemia 
resulted  in  asphyxia  and  starvation  of  the  cells.  A  long  con- 
tinued venous  stasis  must  affect  the  vessel  walls  in  much  the 
same  way,  since  it  also  decreases  the  oxygen  and  nutritive  sup- 
ply. In  chronic  nephritis  there  is  usually  a  marked  anemia 
with  hydremic  blood  and  this  appears  before  the  edema.  From 
experiments  by  Bolton,  one  may  conclude  that  edema  results 
solely  because  of  this  series  of  changes  occasioned  by  the  stag- 
nation of  blood  in  dilated  veins  and  that  plethora  or  increased 
capillary  tension  are  neither  of  them  necessary  for  the  produc- 
tion of  edema.  These  facts  have  led  Starling  to  the  belief  that 
alterations  in  the  endothelium  of  the  capillary  wall  must  be  re- 
garded as  the  essential  factor  in  the  production  of  edema.  The 
retention  of  nitrogenous  wastes  in  nephritis  must  be  an  added 
cause  of  injury  to  the  vessels.  With  these  facts. in  mind,  the 

11  Starling— Fluids  of  the  Body,  p.  159. 

12  Ibid.,  p.  162. 

23 


354  SYSTEMIC  AND  METABOLIC  DISEASES 

rationale  of  hydriatic  treatment  is  quite  evident.  The  restora- 
tion of  tone  to  the  vessels,  both  blood  and  lymph,  hastens  the 
circulation,  thus  relieving  the  stasis  and  consequently  improving 
the  nutrition  of  the  vessel  walls.  The  nutritive  processes  and 
activity  of  the  endothelial  cells  are  directly  stimulated  by  hydri- 
atic applications.  In  short,  the  entire  series  of  morbid  changes 
from  the  decreased  permeability  of  the  kidneys  to  the  venous 
stasis  and  increased  permeability  of  the  vessel  walls,  is  met  by 
the  one  agent — warm  water.  There  is  no  evidence  that  free 
water  drinking  is  harmful  in  edema  where  the  amount  of 
urine  is  less  than  normal.  On  the  contrary,  it  has  been  shown 
that  plethora  is  not  a  contributing  factor  in  edema.  The  diu- 
resis it  induces  greatly  lessens  nitrogenous  retention  and  thus, 
by  decreasing  the  toxemia,  aids  recovery. 

Acute  Nephritis.  Beginning  as  it  does  as  an  acute  imflam- 
mation  and  passing  through  the  various  stages  of  the  inflam- 
matory process,  acute  Bright's  disease  should  be  treated  along 
the  lines  laid  down  for  inflammations.  The  peculiar  course  of 
the  disease  is  governed  by  the  anatomic  and  physiologic  re- 
lations of  the  kidneys,  organs  of  necessarily  constant  activity, 
and  activity  of  such  a  character  that  it  must  militate  against 
their  recovery.  The  kidney  is  congested,  swollen,  edematous, 
and  tense  at  the  onset  of  the  first  symptoms;  later,  venous  stasis 
is  the  predominating  physical  change.  To  relieve  these  condi- 
tions, sweating  measures  have  abundantly  proven  their  superior- 
ity. These  congest  the  skin  and  relieve  the  kidney  congestion. 
The  patient' should  perspire  freely  for  an  hour  or  more,  at  least 
once  a  day.  'The  skin  should  be  warm  and  moist  all  of  the 
time.  Free  diaphoresis  may  be  accomplished  in  several  ways. 
It  is  often  best  to  resort  to  some  of  the  milder  measures,  such 
as  the  hot  foot  bath  with  fomentations  to  the  abdomen  or  spine, 
or  the  hot  trunk  pack.  If  the  symptoms  are  urgent,  the  full 
'hot  pack  may  be  used.  The  head  should  be  kept  cool,  and  if 
the  pulse  is  over  100,  an  ice  bag  placed  over  the  heart.  During 
the  sweat,  copious  water  drinking  should  be  encouraged.  This 
favors  diaphoresis,  and  as  soon  as  the.  renal  congestion  lessens, 
it  aids  in  diuresis.  The  patient  may  be  sponged  off  with  tepid 
water  and  then  placed  between  warm  blankets  to  continue  per- 


NEPHRITIS  355 

spiring,  gently  for  an  hour  or  longer.  A  brisk  cold  mitten  fric- 
tion so  given  that  the  part  treated  is  immediately  dried,  rubbed 
with  the  dry  hand  until  warm,  and  then  covered  with  the  warm 
dry  blanket,  will  prove  a  valuable  adjunct  to  the  sweating 
measure.  It  improves  the  general  vitality  and  helps  restore 
the  cardio-vascular  mechanism  to  normal  tone.  Frequent  re- 
petition of  the  warm  saline  enema  is  unrivaled  in  the  preven- 
tion and  treatment  of  the  uremia  of  acute  .nephritis.  General 
cold- applications,  i.  e.,  cold  applied  to  a  large  surface  at  one 
time,  such  as  the  cold  towel  rub  or  wet  sheet,  are  contraindicated. 
The  cold  mitten  friction  given  as  described  above  counteracts 
the  depressing  tendency  of  the  sweating  measures  which  must 
be  repeated  daily.  The  alcohol  rub  may  be  used,  but  it  lacks 
the  tonic  effect  obtained  from  the  cold.  The  hot  air  bath,  so 
prepared  that  it  can  be  given  in- bed,  is  an  excellent  means  of 
producing  perspiration  (Plate  XVII.}.  Croftan13  objects  to  the 
use  of  dry  heat  in  cases  unaccompanied  by  edema,  claiming 
that  it  increases  the  concentration  of  the  blood.  He  favors  the 
use  of  the  full  warm  bath  in  acute  nephritis.  This  should  be 
at  a  temperature  of  98° — 104°  F.,  continued  for  ten  or  fifteen 
minutes.  Others  recommend  a  temperature  not  over  100°  F. 
in  subacute  nephritis,  and  the  prolonging  of  the  bath  from  thirty 
to  sixty  minutes.  During  this  time,  the  head  and  face  should 
be  bathed  in  cold  water  or  cold  compresses  applied  to  the  head 
and  neck.  The  tub  should  be  covered  with  a  sheet  in  order  to 
limit  the  cooling  of  the  surface,  and  when  the  patient  is  removed, 
the  room  temperature  must  be  85°  or  more  to  guard  against 
chilling.  The  patient  should  be  immediately  placed  between 
dry  blankets,  or  in  a  sheet  and  well  covered  by  warm  dry 
blankets  and  allowed  to  remain  in  this  heating  pack  for  a  time. 
The  electro-thermal  pack  is  a  very  convenient  substitute  for  the 
dry  pack. 

During  the  first  few  days  of  acute  nephritis,  in  case  it  seems 
necessary  to  use  the  hot  trunk  pack  or  full  hot  blanket  pack, 
an  ice  bag  may  be  applied  over  the  lower  third  of  the  sternum. 
It  tends  to  cause  reflex  vaso-constriction  in  the  kidney.  With 
these  intensely  hot  applications,  an  ice  bag  over  the  heart  is 

13    Clinical  Therapeutics. 


S56  SYSTEMIC  AND  METABOLIC  DISEASES 

usually  necessary  and,  if  a  large  ice  cap  is  used,  it  will  cover 
the  sternal  kidney  area  as  well .  Other  forms  of  hot  bath ,  such 
as  the  Russian  and  electric  light,  may  be  best  left  for  subacutc 
or  chronic  nephritis  after  the  acute  symptoms  have  largely 
subsided. 

Chronic  Nephritis.  In  chronic  nephritis,  whether  a  sequel 
of  the  acute  or  coming  on  insidiously  and  complicated  by 
cardiac  and  vascular  changes,  it  is  possible  to  utilize  a  greater 
variety  of  measures  and  more  vigorous  tonics  can  be  borne.  A 
southern  climate  is  of  advantage  largely  because  free  perspira- 
tion is  secured  without  effort  and  there  is  less  tendency  to  chill- 
ing. We  have  utilized  with  success  all  hot  baths,  such  as  the 
Russian,  Turkish,  electric  light,  and  superheated  air.  These 
may  be  given  two  or  three  times  a  week.  About  once  a  week 
or  once  in  two  weeks,  it  is  desirable  to  follow  a  vigorous  sweat- 
ing treatment  by  the  Turkish  shampoo.  All  these  extreme- 
sudorific  treatments  should  be  concluded  by  some  form  of  the 
hot  and  cold  shower,  douche,  or  spray.  The  douche  is  the  best 
means  since  it  combines  percussion  effects  with  the  thermic 
stimulus  and  so  lessens  the  tendency  to  chilling.  The  alternate 
application  of  fomentations  and  an  ice  bag  to  the  lower  sternum 
and  kidney  region  produces  mild  fluxion  in  the  kidney.  The 
alternate  hot  and  cold  percussion  douche  to  the  lower  sternum 
and  the  lower  dorsal  and  lumbar  regions  is  more  vigorous  and 
a  very  efficient  means  of  stimulating  renal  activity. 

Nearly  all  hydriatists  recommend  very  highly  the  full  warm 
bath  as  the  most  serviceable  measure  in  subacute  nephritis. 
While  we  do  not  doubt  its  great  utility,  yet  we  have  seen  better 
results. by  employing,  in  about  two  out  of  every  three  treat- 
ments, more  vigorous  means  and  means  employing  more  tonic- 
effects.  These  are  obtained  to  only  a  slight  extent  by  the  warm 
bath.  Where  there  are  marked  changes  in  the  heart  and  ves- 
sels, we  have  found  tonic  hydrotherapy  a  necessity.  Of  tonic 
measures,  one  may  use  hot  and  cold  to  the  spine,  the  revulsive 
compress  to  the  kidney  region  or  abdomen,  the  cold  mitten 
friction,  the  ice  bag  to  the  heart,  and  the  alternating  douche. 
The  Nauheim  bath  is  highly  recommended  both  for  the  relief 
of  dropsy  and  the  treatment  of  cardio- vascular  disturbances. 


NEPHRITIS  357 

That  it  is  a  powerful  means  can  not  be  doubted.  It  must, 
however,  be  used  with  caution,  remembering-  that  it  may  result 
in  overs timulation.  For  the  edema  of  the  feet  and  legs,  alter- 
nate hot  and  cold  immersion  is  as  valuable  as  for  the  same 
condition  in  cardiac  incompetency.  Its  beneficial  action  may  be 
assisted  by  massage. 

Cathartics  and  Medicinal  Diaphoretics.  About  the  only  dia- 
phoretic drug  recommended  as  a  routine  is  pilocarpin.  This 
must,  however,  be  mentioned  only  to  be  condemned.  It  is  dan- 
gerous where  the  heart  may  be  involved  in  the  general  vascular 
changes  and  its  use  is  entirely  superfluous,  since  we  have  such 
efficient  hydriatic  means  of  accomplishing  the  same  results. 
Saline  cathartics  or  elaterium  as  a  means  of  reducing  ascites  or 
anasarca  may  at  times  be  necessary.  Their  repeated  use  is  not 
to  be  encouraged,  since  they  induce  great  weakness  and  derange 
the  digestion.  Diuretin  should  not  be  used  in  any  form  of  ne- 
phritis since  it  irritates  the  renal  epithelium.  It  is  necessary 
that  special  attention  be  paid  to  gastric  digestion.  The  measures 
recommended  for  the  various  forms  of  atonic  indigestion  should 
be  used  as  indicated.  Attention  should  also  be  given  the  gas- 
trectasia  which  so  frequently  accompanies  a  chronic  parenchyma- 
tous  nephritis.  It  is  a  cause  of  faulty  nutrition  and  is  closely 
connected  with  morbid  proteid  metabolism.  The  free  use  of 
mineral  waters  may  greatly  increase  the  dilatation.  Fluids 
must  be  taken  in  small  amounts,  preferably  as  plain  cold  water. 
In  interstitial  nephritis,  mineral  waters  or  even  the  free  use  of 
ordinary  water  is  unnecessary,  since  diuresis  is  the  rule.  In 
this  form,  whether  simple  or  forming  part  of  a  general  arterio- 
sclerosis, extreme  measures,  either  hot  or  cold,  are  usually  con- 
traindicated  since  the  increase  of  blood  pressure  which  both 
produce  may  determine  an  apoplexy.  However,  in  some  cases 
of  chronic  nephritis  accompanying  obesity  the  most  vigorous 
sweating  measures  followed  by  vigorous  hot  and  cold  sprays 
and  douches  are  taken  with  benefit  and  marked  reduction  in 
blood  pressure.  Mild  diaphoresis  is  beneficial  and  this  may  be 
secured  by  short  hot  baths  or  the  prolonged  warm  bath  at  a 
temperature  of  98°  or  99°.  This  tends  to  equalize  the  blood 
pressure  and  helps  to  relieve  the  nerve  tension  which  is  a  part 
of  the  clinical  picture  in  many  of  these  cases. 


S58  SYSTEMIC  AND  METABOLIC  DISEASES 

It  has  recently  been  shown  that  the  endogenous  uric  acid  in 
the  blood  in  interstitial  nephritis  varies  according-  to  the 
functional  activity  of  the  kidneys."  These  observations  were 
made  on  a  purin-free  diet.  This  retention  of  uric  acid  is  very 
favorably  influenced  by  exercise  and  hydrotherapy.  Umber 
noticed  that  on  a  purin-free  diet  the  elimination  of  uric  acid 
decreased  after  exercise,  owing  to  its  participation  in  the  in- 
creased oxidation  incident  to  muscular  exertion.  That  like  re- 
sults may  be  obtained  by  hydrotherapy  has  been  shown  by  the 
researches  of  Strasser. 

UREMIA  AND  ECLAMPSIA 

These  pathologic  states,  while  not  identical,  have  many  points 
in  common.  In  uremia,  there  is,  in  the  majority  of  cases,  a 
retention  of  toxic  urinary  products  because  of  the  kidney  insuf- 
ficiency. While  all  observers  are  not  agreed  as  to  the  constant 
occurrence  of  kidney  insufficiency  in  eclampsia,  yet  nearly  all 
agree  that  its  manifestations  are  accompanied  by  a  severe  poison- 
ing from  some  autotoxic  source.  Croftan  says  there  is  much 
chemical  and  clinical  evidence  to  show  that  in  uremia  the  gen- 
eral metabolism  and,  in  particular,  the  manifold  functions  of  the 
liver,  are  perverted.  The  kidney  may  not  be  primarily  involved 
and  possibly  in  some  few  cases  not  at  all.  In  the  majority  of 
cases,  however,  there  are  demonstrable  lesions  in  the  kidney 
as  well  as  functional  inadequacy  during  life.  A  great  variety 
of  conditions  have  been  reported,  among  which  are  infarcts, 
acute  and  chronic  congestion,  edema,  greatly  increased  tension, 
and  actual  nephritis.  In  a  case  of  eclampsia  reported  by 
Wiemer 15  the  tension  was  so  marked  that  the  kidney  substance 
bulged  out  on  incision  in  the  course  of  Edebohl's  operation. 
Braak  and  Mijnlieff  16  report  a  case  in  which  the  right  kidney 
was  much  enlarged  and  so  painful  that  the  patient,  in  coma, 
reacted  when  it  was  palpated.  They  report  thirteen  other  cases 


14  In  gout  the  endogenous  uric  acid  in  the  blood  is  more  constant  and  never  exceeds  a 
certain  maximum   amount    (about   0.003  per  cent).     A  demonstrable    amount  of  uric 
acid  is  always  present  in   the  blood  in  gout,  even  when  the  food  has  been  free  from 
punns  for  weeks  or  months,  while  blood  from  normal  individuals  on  a  purin-free  diet 
contains  no  uric  acid.— Journal  of  American  Medical  Association,  April  3,  1909,  p.  1110. 

15  Monatschrift  fur  Geburtsh  und  Gynakologie,  March.  1908. 

16  Centralblatt  fflr  Gynakologie,  October  19,  1908. 


UREMIA  359 

of  eclampsia  accompanied  by  increased  tension  in  the  kidney. 
All  were  treated  by  decapsulation  and,  with  one  exception, 
recovered.  Franck  reports  ten  cases  with  no  bulging  or 
increased  intracapsular  tension. 

Hepatic  changes  are  almost  universally  present.  In  fact, 
functional  and  structural  alterations  of  the  kidneys  and  liver 
are  very  frequently  associated.  Their  functions  are  consecu- 
tive, i.  <?.,  the  liver  is  the  chief  agent  in  the  preparation  of 
wastes  for  excretion  and  the  kidneys  receive  these  for  purposes 
of  excretion.  This  naturally  leads  to  the  view,  which  is  also 
supported  by  clinical  analyses,  that  in  many  cases  the  decrease 
of  urea  in  the  urine  is  due  not  to  failure  in  its  elimination,  but 
to  failure  in  its  formation  from  the  various  precursors,  includ- 
ing the  ammonia  compounds;  uremia  then,  being  due  to  these 
toxic  antecedents,  rather  than  to  poisons  retained  with  the  urea, 
and  of  the  amount  of  which  the  decreased  urea  excretion  is  a 
gauge.  "  Somewhere  in  the  organism  there  is  a  deficient 
changing  of  ammonia  and  amino-acids  into  urea.  This  has 
been  called  '  deficient  desamidation  '  by  Ewing,  who  asserts 
that  the  process  is  no  more  than  an  oxidation.  This  work  is  in 
a  great  measure  performed  by  the  liver,  and  therefore  we  are 
not  surprised  to  find  the  liver  most  severely  involved."  17 

In  this  connection  it  is  interesting  to  note  the  relation  of  one 
of  the  chief  causes  of  uremia  and  eclampsia,  viz.,  a  diet  rich 
in  meat,  to  the  size  of  the  liver.  Dr.  Chalmers  Watson 18  calls 
attention  to  the  difference  in  the  size  of  the  liver  in  meat-fed 
rats  and  in  bread-and-milk-fed  rats.  From  an  examination  of 
the  livers  in  the  two  cases,  it  was  shown  that  the  average  liver 
weight  of  the  meat-fed  rats  was  6  grams,  while  the  average 
liver  weight  of  the  bread-and-milk-fed  rats  was  4  grams.  The 
meat  diet  had  caused  an  increase  of  50  per  cent  in  the  size  of 
the  liver. 

Moreover  it  has  been  shown  that  a  severe  acidemia  may  cause 
the  convulsions  and  coma  characteristic  of  uremia  and  eclamp- 
sia. Were  this  the  case,  sweating  treatment,  if  much  pro- 


17  Davis  and  Foulkrod— The  Etiology  of  Eclampsia— Journal  of   American  Medical 
Association,  January  7,  1911,  pp.  11,  12. 

18  London  Lancet,  October  12.  1907. 


S60  SYSTEMIC  AND  METABOLIC  DISEASES 

longed,  would  only  deepen  the  difficulty  since,  if  unaccompanied 
by  cold,  it  increases  the  acidosis. 

For  practical  purposes,  we  may  divide  the  treatment  into  two 
parts:  First,  the  treatment  of  chronic  uremia,  the  conditions 
that  predispose  to  the  acute  attack,  and  the  pre-eclamptic  state; 
second,  the  treatment  of  the  acute  attack  of  uremia  or  eclamp- 
sia, the  convulsive  seizures  and  coma.  It  should  be  borne  in 
mind  that  in  eclampsia  a  neurotic  temperment  predisposes  to 
the  attack  and  that  there  is  the  added  factor  of  pregnancy 
which  may,  in  spite  of  vigorous  treatment,  demand  hasty 
emptying  of  the  uterus. 

"  Chronic "  Uremia  and  the  Pre-eclamptic  State.  The  prin- 
ciples involved  in  the  treatment  of  faulty  nitrogenous  metabo- 
lism have  been  discussed  in  the  consideration  of  gout  and 
Bright' s  disease.  Those  persons  living  upon  a  highly  nitrog- 
enous diet,  containing  purins,  are  predisposed  to  the  uremic 
state.  Women  who  partake  heavily  of  tea  and  coffee  are  pre- 
disposed to  eclampsia.  The  reason  for  this  is  that  the  caffcin 
greatly  increases  the  amount  of  basic  purins  which  must  there- 
fore be  raked  over  by  the  liver  and  thrown  out  by  the  kidneys. 

Alfred  Schittenhelm  19  has  shown  by  experiments  upon  dogs 
the  extent  to  which  caffein  increases  basic  purins  and  uric  acid. 
We  give  below  a  table  of  averages  which  shows  these  items. 
The  dog  was  kept  on  a  purin-free  diet  previous  to  the  tests. 
The  pre -period  lasted  three  days.  For  three  days  following 
this,  three  daily  doses  each  of  0.3  grams  of  caffein  were  admin- 
istered. Next  intervened  a  period  of  two  days  with  purin-free 
diet,  and  following  this  the  same  daily  amount  of  theobromin 
(as  previously  of  caffein)  was  given  for  two  days. 


THEOBROMIN 


Uric  acid  in  gm.  N.         0.006       0.008       0.006       0.007       0.006 
Purin  bases  in  gm.  N.    0.005       0.026       0.009       0.013       0.008 

Chronic  congestion  of  the  liver  as  pointed  out  above  and 
hepatic  cirrhosis  are  also  factors  in  the  causation  of  uremia. 
The  vicious  cycle  and  disordered  liver  accompanying  periodic 

19    Zur  Frage  der  harnsaurevermehrenden   Wirkung  von   Kaffee  und  Tee  und  ihrer 
Bedeutung-  in  der  Gichttherapie— Therapeutist-he  Monatshefte,  March,  1910,  p.  115. 


UREMIA  361 

sick  headaches  are  additional  causes.  These  conditions  de- 
mand the  exclusion  of  purins — meat,  tea,  and  coffee — from  the 
diet,  and  the  limitation  of  proteins.  The  diet  should  consist 
largely  of  carbohydrates,  milk,  fresh  vegetables,  and  fruits. 
Hydriatic  treatment  should  be  directed  toward  the  oxidation 
and  elimination  of  nitrogenous  wastes.  As  a  means  to  this  end, 
special  attention  should  be  given  to  the  liver  activity,  the  cir- 
culation, and  renal  activity.  Extreme  diaphoresis  is  not  neces- 
sary, but  gentle,  free  perspiration  should  be  encouraged.  To 
this  end,  short  electric  light  baths  may  be  used  once  or  twice  a 
week.  More  or  less  perspiration  accompanies  the  use  of  local 
hot  applications,  such  as  the  hot  foot  bath  with  fomentations  to 
the  abdomen  and  spine,  warm  showers  and  douches.  A  regu- 
lar course  of  tonic  treatment  should  accompany  these  meas- 
ures. Of  these,  may  be  used  hot  and  cold  to  the  spine,  re- 
vulsive compress,  cold  frictions,  alternate  showers,  sprays,  and 
douches.  The  neutral  or  warm  tub  bath  is  an  excellent  means 
of  quieting  nervous  symptoms  and  equalizing  blood  pressure. 
The  patient  should  drink  water  freely  and  frequently.  Fomen- 
tations and  the  revulsive  compress  to  the  liver,  also  the  alternate 
douche  to  the  hepatic  region,  are  efficient  chologogues  and 
stimulate  all  the  other  hepatic  functions.  In  case  pregnancy 
is  complicated  by  a  pre-existing  nephritis,  the  patient  should  be 
under  constant  observation  and  treatment.  The  measures 
recommended  for  chronic  Bright 's  disease  may  be  employed. 
Acute  Uremia  and  Eclampsia.  So  successful  have  diapho- 
retic measures  proven  in  these  conditions  that  they  are  almost 
specific.  The  repeated  use  of  prolonged  sweating  treatments  is 
not  advisable  unless  there  is  a  favorable  response  from  the  first 
or  second  application.  The  measure  which  has  given  best  re- 
sults is  the  full  hot  blanket  pack  accompanied  by  the  ingestion  of 
an  abundance  of  water.  It  may  be  necessary  to  use  saline  solu- 
tion by  hypodermoclysis  or  enteroclysis.  This  can  not  result 
in  damage  from  increase  of  blood  pressure  if  the  patient  is 
perspiring  freely.  Many  cases  have  been  reported  in  which 
the  giving  of  saline  solution  resulted  in  prompt  diuresis.  It 
dilutes  the  blood,  decreases  the  toxemia  and  favors  elimination 
by  the  skin  and  kidneys.  It  may  be  necessary  to  somewhat 


S62  SYSTEMIC  AND  METABOLIC  DISEASES 

prolong  the  hot  pack.  Whenever  it  is  used,  the  cerebral  circula- 
tion should  be  guarded  by  the  cold  compress,  ice  bag,  or  cold 
affusions  to  the  head.  An  ice  bag  should  also  be  used  over  the 
heart.  The  patient  may  be  removed  from  the  pack  by  a  wet 
hand  rub  or  other  cold  friction  and  put  between  blankets  to 
continue  perspiring  gently.  Croftan,  Edwards,  and  others  favor 
the  use  of  the  full  hot  bath  as  recommended  by  Liebermeister. 
The  bath  begins  at  98°  or  thereabouts  and  is  generally  run  up 
5°  or  6°,  the  head  being  kept  cool  by  cold  affusions. 

The  rationale  of  these  sweating  treatments  lies  not  alone  in 
the  elimination  of  toxins  by  the  skin.  In  fact,  we  believe  this 
is  only  a  part,  and  perhaps  often  a  small  part  of  the  real  effect. 
Soon  after  free  diaphoresis  has  been  established,  urinary  secre- 
tion begins  to  increase  and  may,  in  acute  suppression,  appear 
very  promptly.  This  is  doubtless  due  to  the  relief  of  the  kid- 
ney congestion  and  the  reduction  of  renal  edema  and  increased 
tension  in  those  cases  in  which  these  occur.  Relieving  renal 
stasis  always  results  in  freer  excretion  of  urine.  The  case  of 
eclampsia  with  great  enlargement  of  the  kidney  mentioned 
above  as  reported  by  Braak  and  Mijnlieff ,  having  refused  opera- 
tion, recovered  under  the  use  of  wet  packs  with  hot- water 
bottles  and  medicinal  measures.  The  coma  subsided  and  the 
kidney  gradually  returned  to  normal  size.  O.  M.  Hayward 
reports  a  case20  of  eclampsia  in  which  two  hot  packs  failed  to 
relieve  the  coma.  With  the  patient  deeply  comatose,  pulse  160 
and  very  weak,  axillary  temperature  105.2°  F.,  and  respiration 
irregular  and  gasping,  she  was  wrapped  in  a  sheet,  placed  on  a 
table,  and  a  cold  rubbing  pour  administered.  In  five  minutes 
there  was  some  improvement  and  the  cold  pour  and  rubbing  were 
continued.  In  thirty  minutes  the  patient  was  returned  to  bed 
with  a  temperature  of  100°  F.,  pulse  100,  and  respiration  nearly 
normal .  The  failure  in  the-  hot  pack  was  doubtless  due  to  the 
fact  that  it  was  unaccompanied  by  a  cold  friction.  This  might 
have  been  administered  by  the  cold  mitten  or,  as  was  done 
later,  by  the  cold  pour  and  rubbing  wet  sheet  pack. 

The  use  of  a  large  ice  cap  to  the  heart  and  over  the  lower 
third  of  the  sternum  is  desirable  and  usually  necessary. 

20  Modern  Medicine,  March,  1908.  p.  60. 


CHAPTER  XXV 
PEPTOGENIC  EFFECTS 

THIS  term — "  peptogenic  effects  " — is  here  used  to  designate 
a  variety  of  effects  upon  the  digestive  organs  and  diges- 
tive activity  in  the  sense  of  increasing  the  efficiency  of  these 
organs  and  functions.  The  measures  directed  toward  improv- 
ing the  digestion  also  increase  the  activity  of  the  liver.  All 
tonic  treatments  increase  the  muscular  and  glandular  activity 
of  the  stomach  and  intestines,  also  the  glandular  activity  of  the 
liver  and  pancreas.  They  aid  digestion  and  sharpen  the  appe- 
tite. In  addition  to  general  tonic  treatments,  it  is  necessary  to 
direct  special  attention  to  the  digestive  organs  themselves. 
The  following  are  some  of  these  special  treatments  which  are 
useful  in  promoting  digestion  and  absorption: — 

1.  Winternitz  pack  (hot  and  heating  trunk  pack). 

2.  Hot  trunk  pack. 

3.  Fomentations  to  the  abdomen. 

4.  Revulsive  compress  to  the  abdomen. 

5.  Hot  and  cold  to  the  spine. 

6.  Hot  and  cold  douche  to  the  abdomen,  liver,  and  spine. 

7.  The  umschlag  (moist  abdominal  girdle). 

8.  Hot- water  bottle  or  Winternitz  coil  over  the  stomach  after 
a  meal. 

.9.   Ice  bag  over  the  stomach,  or  cold  water  drinking,  before  a 
meal. 

These  treatments  properly  selected  to  meet  the  needs  of  the 
individual  case  are  indicated  in, — 
1.  All  forms  of  atonic  indigestion. 

(a)  Hypochlorhydria. 

(b)  Anacidia. 


364  PEPTOGENIC  EFFECTS 

(c)  Gastrectasia. 

(d)  Gastroptosis. 

(e)  Lowered  gastric  motility. 

(f)  General  splanchnoptosis. 

(g)  Biliousness. 

(h)  Periodic  sick  headaches  (in  interval), 
(i)    Amylaceous  dyspepsia. 

2.  Chronic  congestion  of  liver. 

3.  Anemia  of  liver. 

ATONIC  DYSPEPSIA 

This  term  is  not  used  in  its  ordinary  restricted  sense  as  apply- 
ing alone  to  painful  digestion.  We  use  it  here  to  designate  a 
great  variety  of  digestive  disorders  associated  with  deficient 
gastric  secretion,  and  lessened  motility  with  more  or  less  dis- 
tress or  discomfort  after  meals.  These  various  conditions  may 
be  grouped  in  this  manner  for  convenience  in  considering  their 
hydriatic  management,  for  this  must  be  carried  on  along  much 
the  same  lines  in  all .  The  aim  is  to  produce  a  general  increase 
of  tone  in  both  the  glands  and  musculature  of  the  digestive 
organs.  We  hardly  need  mention  that  special  attention  must 
be  paid  to  the  matter  of  diet,  exercise,  rest,  favorable  environ- 
ment, etc.  These  are  all  of  prime  importance. 

In  the  more  severe  grades  of  defective  digestion,  something 
like  the  following  program  should  be  carried  out: — 

Half  an  hour  before  the  meal,  the  patient  should  be  instructed 
to  take  half  a  glass  of  cold  water  or  even  ice  water.  Bits  of  ice 
or  a  small  amount  of  fruit  ice  may  be  taken  twenty  minutes  to 
half  an  hour  before  the  meal.  Instead  of  cold  internally,  an  ice 
bag  may  be  placed  over  the  stomach  beginning  half  or  three 
quarters  of  an  hour  before  the  meal  and  continued  for  ten  or 
fifteen  minutes.  The  skin  over  the  stomach  should  warm  up 
before  the  meal  is  taken.  This  will  require  about  fifteen  min- 
utes after  the  ice  bag  has  been  removed.  The  philosophy  of 
these  measures  lies  in  the  fact  that  the  cold  application  produces 
a  reaction  which  comes  on  at  the  time  the  meal  is  taken,  so  that 
the  glandular  activity  is  increased  during  the  period  of  digestion. 

The  experimental  basis  of  this  old  and  very  successful  means 


ATONIC  DYSPEPSIA  365 

of  promoting:  gastric  secretion  has  been  worked  out  by  Doctor 
Kasanski  in  the  laboratory  of  Prof.  I.  P.  Pavlov.1  By  the  appli- 
cation of  cold,  the  activity  of  the  gastric  glands  is  arrested  while 
the  cold  continues.  After  the  removal  of  the  cold,  the  work  of 
the  glands  rises  above  the  normal  and  continues  at  a  higher 
point  for  a  longer  time.  In  the  following  table  will  be  noted 
the  result  of  intense  cold  applied  during  the  first  hour  of  the 
digestive  period.  The  reaction  comes  on  during  the  second 
hour. 

HOUR  NORMAL  SECRETION  SECRETION   AS 

AFFECTED   BY  COLD 

1st  11.6  c.  c.  6.2  c.  c. 

2nd  8.4     "  11.6     " 

3rd  3.5  10.8     " 

4th  1.9     "  5.6     " 

5th  1.3     "  3.6     " 

In  cases  of  extreme  anemia  a  small  amount  of  a  hot  soup  or 
hot  beverage  should  be  used  just  previous  to  the  meal,  as  there 
is  not  sufficient  vitality  to  react  to  the  cold  drink.  Following 
the  meal,  the  patient  should  use  a  hot-water  bottle 'over  the 
stomach.  This  should  be  continued  for  twenty  minutes  to  an 
hour,  or  even  longer.  In  more  severe  cases,  the  Winternitz 
pack  {Plate  XVIII.}  will  be  found  very  efficient.  It  should  be 
applied  immediately  after  the  meal,  or  the  pack  may  be  applied 
first  and  the  meal  eaten  while  the  patient  is  in  the  pack.  It 
should  be  continued  for  from  thirty  minutes  to  as  long  as  two 
or  three  hours,  and  be  concluded  with  a  cold  mitten  friction. 
In  applying  the  pack  the  hot-water  bottle  may  be  used  in  place 
of  the  Winternitz  coil  {Plate  XIX.}.  Since  a  constant  tempera- 
ture can  not  be  maintained  by  the  hot- water  bottle,  the  treat- 
ment is  not  so  effectual.  Fomentations  of  moderate  heat  may 
be  applied  to  the  abdomen  over  the  stomach  and  liver,  immedi- 
ately following  a  meal.  Two  or  three  hours  after  the  meal, 
the  patient  may  be  given  a  treatment  consisting  of  a  hot  foot 
bath  with  a  revulsive  compress  to  the  abdomen,  or  hot  and  cold 
to  the  spine,  together  with  the  cold  mitten  friction  or  cold  towel 


1  Work  of  the  Digestive  Glands,  Second  English  Edition,  pp.  239,  240. 


S66  PEPTOGENIC  EFFECTS 

rub.  Other  applications  which  may  be  used  are  the  hot  and 
cold  douche  to  the  abdomen  and  liver,  also  to  the  spine.  At 
night  it  is  well  to  apply  the  moist  abdominal  girdle.  It  should 
be  dry  by  morning-.  The  protected  g-irdle  is  not  used  in  this 
condition. 

In  addition  to  these  hydriatic  measures,  the  patient  should  be 
given  general  massag-e  with  special  abdominal  massag-e,  vibra- 
tion to  the  abdomen,  faradic  or  sinusoidal  electricity  to  abdo- 
men and  spine,  or  the  Morton  wave  to  the  abdomen  and  spine. 
Since  these  various  measures  are  not  applicable  to  all  cases  of 
atonic  dyspepsia,  they  should  be  selected  according-  to  the  needs 
of  the  individual  case.  All  of  them,  with  the  exception  of 
fomentations  to  the  abdomen  and  the  hot  trunk  pack,  are  con- 
traindicated  in  hyperchlorhydria  and  gastric  or  duodenal  ulcer 
with  much  hemorrhage. 

Patients  with  dyspepsia  soon  become  accustomed  to  cold 
applications  and  may  be  given  most  vigorous  tonics.  After  a 
week  or  so  of  treatment  a  general  cold  affusion  or  pail  pour 
may  be  used  daily.  The  cold  wet  sheet  rub  may  also  be  used 
after  tolerance  for  douches  and  pail  pours  has  been  acquired. 
The  cold  morning  plunge  is  not  excelled  as  a  general  tonic 
and  exerts  a  beneficial  action  on  digestion.  It  sharpens  the 
appetite,  thus  aiding  in  the  production  of  "psychic  juice" 
which  Pavlov  assures  us  is  five  times  as  efficient  in  gastric 
digestion  as  the  chemically  excited  secretion. 

Pavlov  has  further  shown  that  another  of  the  circumstances 
favorable  to  the  activity  of  the  gastric  glands  is  an  abundant 
supply  of  water  in  the  organism.  He  says,2  "  One  of  these 
favoring  circumstances  we  discovered  in  the  introduction  of 
large  quantities  of  water  into  the  system.  We  based  this  upon 
earlier  facts,  showing  that  the  quantity  of  juice  was  strikingly 
dependent  upon  the  amount  of  water  in  the  organism."  This 
makes  clear  the  necessity  for  free  water  drinking  between  meals 
in  order  to  provide  fluid  for  the  formation  of  the  requisite  amount 
of  gastric  juice. 

In  cases  of  motor  insufficiency  associated  with  marked  dila- 
tation, cold  drinks  can  not  be  used  before  the  meal,  since  there 

J     Work  of  the  Digestive  Glands,  Second  English  Edition,  p.  245. 


PLATE  XVIII.     Winternitz  pack  (hot  and  heating  trunk  pack). 


PLATE  XIX.    AVinternitz  pack  (with  hot-water  bottle). 


ATONIC  DYSPEPSIA  S67 

is  not  sufficient  power  to  empty  the  stomach  in  so  short  a  time 
and  the  circulatory  reaction  is  much  delayed.  Before  the  meal, 
the  patient  may  be  placed  on  a  table  or  slab  and  a  cold  affusion 
administered  to  the  abdomen.  This  should  be  intermittent,  as 
it  will  be,  if,  by  means  of  a  large  dipper,  water  is  dipped  from 
a  pail  and  poured  over  the  abdomen.  The  temperature  of  the 
water  at  first  should  be  about  75°  F.  and  gradually  reduced  to 
45°  or  50°  F.  One  full  pail  of  water  will  usually  suffice  for  a 
single  treatment. 

Douching  the  mucous  membrane — lavage  of  the  stomach — 
with  cold  water  may  be  found  helpful.  This  measure,  combined 
with  intragastric  electricity,  is  a  most  efficient  means.  After 
swallowing  a  glass  of  cold  water  the  gastric  electrode  is  intro- 
duced and,  by  means  of  either  an  abdominal  sponge  or  plate 
placed  to  the  mid-dorsal  spine,  the  slow  sinusoidal  or  slow 
faradic  current  is  given  for  five  to  eight  minutes.  One  may 
frequently  hear  succussion  sounds  or  the  gurgling  of  water 
through  the  pylorus,  caused  by  vigorous  contractions  of  the 
gastric  muscles.  These  treatments  may  be  given  daily  or  on 
alternate  days.  In  one  case,  a  month  of  such  treatment  with 
other  tonic  measures  resulted  in  a  retraction  of  the  greater 
curvature  toward  its  normal  position  of  one  and  one-half  inches 
on  the  left  and  one  inch  upward  in  the  median  line.  On  apply- 
ing for  treatment,  the  greater  curvature  lay  three  inches  below 
and  four  and  one-half  inches  to  the  left  of  the  umbilicus. 

In  connection  with  the  use  of  gastric  lavage,  a  caution  should 
be  uttered  relative  to  the  frequent  use  of  large  quantities  of 
warm  or  hot  water  introduced  into  a  dilated  stomach.  The 
relaxing  effect  is  very  marked  and  in  the  course  of  months  or 
years,  the  stomach  becomes  extremely  dilated  and  entirely  loses 
its  elasticity  and  contractility.  A  few  years  ago  the  author  was 
present  at  the  post  mortem  examination  of  a  man  who  had,  at 
frequent  intervals  for  a  number  of  years,  resorted  to  warm 
gastric  lavage  to  relieve  the  gastric  retention  and  fermentation 
occasioned  by  an  extreme  pyloric  stenosis.  The  stomach  was 
found  to  be  enormous,  reaching  from  the  greatest  height  of  the 
fundus  at  the  level  of  the  fourth  intercostal  space  on  the  left  to 
the  level  of  the  anterior  superior  spines  of  the  ilia,  two  and 


S68  PEPTOGENIC  EFFECTS 

one-half  inches  from  the  right  iliac  spine.  It  would  easily  hold 
one  and  one-half  or  two  gallons.  The  pylorus,  for  a  distance  of 
two  inches,  admitted  with  great  difficulty  a  small  size  lead 
pencil.  The  condition,  of  course,  should  have  been  treated 
surgically  by  some  form  of  pylorectomy. 

The  caution  here  is  not  against  systematic  washing  of  the 
stomach  to  free  it  from  decomposing  remnants  of  food,  but 
against  the  use  of  hot  water  for  this  purpose.  If  it  seems  advis- 
able to  resort  to  gastric  lavage  frequently  and  warm  water  is 
used  first,  it  should  be  followed  by  a  "  dash  "  of,  cold. 

In  those  cases  of  gastric  dilatation  and  lessened  motility  not 
associated  with  pyloric  obstruction,  hydriatic  means  produce 
excellent  results.  In  addition  to  the  measures  recommended 
above,  the  alternate  hot  and  cold  douche  to  the  epigastrium 
may  be  used;  at  first,  with  little  or  no  force,  later,  with  moder- 
ate percussion.  The  percussion  douche  to  the  mid-dorsal  spine, 
also  to  the  legs  and  feet,  serves  as  a  vigorous  tonic.  Gastrec- 
tasia,  associated  with  a  general  splanchnoptosis,  irritable,  ten- 
der sympathetics,  and  a  feeling  of  weight  and  dragging  in  the 
abdomen  may  be  benefited  by  the  cold  sitz-bath  begun  as  a 
graduated  measure.  The  continuous  cold  coil  to  the  abdomen 
acts  in  the  same  way.  The  cold  sitz  may  be  prolonged  to  five 
or  six  minutes  and  the  cold  coil  left  in  place  twenty  to  thirty 
minutes.3 

HYPERCHLORHYDRIA 

Nearly  all  cases  of  indigestion  pass  through  the  stage  of 
hyperacidity  at  the  beginning  of  the  departure  from  normal. 
In  only  a  few,  however,  is  this  condition  so  marked  as  to 
require  special  treatment.  The  patient  is  of  a  nervous  temper- 
ment,  and  eats  rapidly,  swallowing  his  food  with  very  imper- 
fect mastication.  The  free  hydrochloric  acid  may  be  double  or 
even  treble  the  normal  amount.  The  course  to  be  followed  is 
just  the  opposite  to  that  outlined  for  hypochlorhydria.  The 
patient  may  drink  hot  water  or  use  a  hot  application  over  the 
stomach  preceding  the  meal,  after  which  an  ice  bag  should  be 
used  for  twenty  to  thirty  minutes,  or  even  longer.  The  hot 

3    See  also  the  treatment  recommended  for  splanchnic  neurasthenia. 


HYPERCHLORHYDRIA  369 

water  drinking  or  the  hot  application  to  the  epigastrium  pro- 
duces an  atonic  reaction.  In  this  connection  it  should  be  noted 
that  among  the  experiments  performed  by  Professor  Pavlov,  on 
one  occasion  the  work  of  the  large  stomach  was  arrested  for 
several  days  by  the  application  of  -very  hot  water.  Thus  it  will 
be  seen  that  by  applications  of  heat  of  a  suitable  temperature 
an  overactive  state  of  the  gastric  glands  may  be  depressed  and 
their  activity  be  brought  back  toward  normal. 

It  is  needless  to  say  that  dietetic  regulation  is  the  most  im- 
portant factor  in  the  treatment  of  this  condition.  Oils,  whether 
free  or  emulsified,  have  a  specific  inhibitory  action  upon  the 
secretion  of  hydrochloric  acid.  The  patient  should  discard  the 
use  of  meats  entirely.  Other  heavily  proteid  foods  should  be 
interdicted.  Salt  and  condiments  should  be  proscribed.  The 
hyperacidity  may  .be  lessened  by  the  use  of  the  protected  or 
sweating  moist  abdominal  girdle.  Tonic  treatments  should  be 
replaced  by  sedative  measures  such  as  the  neutral  bath,  neutral 
pack,  or  heating  pack.  These  may  be  given  one  or  two  hours 
before  a  meal  or  at  night. 


24 


CHAPTER   XXVI 
HEMOSTATIC  EFFECTS 

CAPILLARY  hemorrhage  and  hemorrhage  from  smaller 
blood-vessels  does  not  usually  require  surgical  treatment. 
Hemorrhage  into  the  hollow  organs  tends  to  check  itself,  pro- 
vided the  circumstances  are  at  all  favorable,  so  that  in  many  cases 
absolute  rest,  accompanied  by  the  use  of  the  ice  bag,  may  pro- 
duce all  that  is  desired.  Thermic  applications  may  be  made 
directly  to  the  part  or  so  as  to  influence  the  blood-vessels  re- 
flexly.  Cold  may  also  be  used  over  the  trunk  of  the  artery  sup- 
plying a  part.  If  heat  is  used  to  check  the  hemorrhage,  the 
application  must  be  very  hot  and  be  made  directly  to  the  bleed- 
ing part.  The  reflex  effect  of  even  very  hot  water  produces 
only  a  transient  narrowing  of  the  vessels,  while  in  a  short  time, 
the  vessels  become  dilated  and  the  hemorrhage  increases.  Cold 
applications  may  be  used  either  to  the  part  itself  or  to  the  reflex 
area.  In  fact,  it  is  quite  a  general  rule  that  cold  is  more  efficient 
through  reflex  action,  while  hot  is  efficient  only  when  applied 
directly  to  the  bleeding  vessels.  In  nearly  every  case  where  ice 
is  used,  it  is  well  to  employ  some  hot  application  for  derivative 
purposes.  The  hot  should  not,  however,  produce  sweating 
since  this  tends  to  dilate  the  blood-vessels  and  increase  the 
hemorrhage. 

Epistaxis 

Thermic  applications  are  often  very  effectual  in  treating  cap- 
illary hemorrhage  from  the  nose.  Very  cold  water  or  very  hot 
water  may  be  drawn  into  the  nose.  An  application  of  ice  may 
be  made  over  the  nose  itself.  Of  the  more  remote  reflex  areas, 
use  may  be  made  of  that  at  the  back  of  the  neck  and  the  hands 
by  having  the  patient  hold  a  chunk  of  ice  at  the  back  of  the 

(370) 


UTERINE  HEMORRHAGE  371 

neck.  The  hands  or  feet  may  be  placed  in  ice  water  or  very 
cold  water  for  a  short  time.  These  applications  should  not  pro- 
duce chilliness. 

Pulmonary  Hemorrhage 

The  patient  should  be  kept  at  absolute  rest.  Warmth  of  the 
body  and  limbs  should  be  maintained,  hot- water  bottles  being- 
placed  to  the  feet,  or,  after  the  hemorrhage  has  somewhat  sub- 
sided, the  patient  may  be  given  a  hot  foot  pack.  That  which 
is  of  most  importance  is  the  applying  of  an  ice  bag  to  the  front 
of  the  chest.  This  should  be  left  in  place  continuously  until  all 
danger  of  hemorrhage  is  passed.  It  should  be  a  large  ice  bag 
or  ice  cap.  This  not  being  available,  the  ice  compress  may  be 
used.  For  some  unknown  reason,  possibly  through  reflex  action, 
the  taking  of  salt  on  the  back  of  the  tongue  is  a  very  efficient 
means  of  quickly  checking  the  hemorrhage. 

Gastric  Hemorrhage 

Gastric  hemorrhage  most  frequently  occurs  in  cases  of  ulcer. 
The  patient  should  be  kept  at  absolute  rest  with  an  ice  bag  over 
the  stomach.  He  may  be  given  cracked  ice  to  swallow.  It  may 
be  necessary  to  apply  a  large  fomentation  over  the  lower  abdo- 
men or  to  other  parts  for  derivative  effects.  The  cold  compress 
is  not  as  efficient  as  the  ice  bag,  having  a  greater  tendency  to 
produce  a  hydrostatic  effect,  while  the  ice  bag-  acts  chiefly 
through  reflex  action. 

Uterine  Hemorrhage 

We  may,  for  convenience,  divide  hemorrhages  from  the 
uterus  into  two  classes:  First,  prolonged  and  profuse  menses; 
and  second,  hemorrhages  following  labor  or  abortion.  The 
means  used  to  check  the  hemorrhage  in  these  two  conditions  is 
usually  quite  different,  since  one  is  acute  and  would  soon  pro- 
duce exsanguination;  the  other  lasting  for  a  number  of  days 
may  be  treated  by  less  vigorous  means.  In  case 'of  profuse 
menses  due  to  subinvolution ,  uterine  vegetations,  small  fibroids, 
etc.,  the  patient  may  be  given  a  cold  sitz  bath.  This  should  be 
prolonged  and  accompanied  by  a  very  hot  foot  bath.  In  some 


S72  HEMOSTATIC  EFFECTS 

cases,  the  shallow  cold  foot  bath  (water  two  or  three  inches 
deep),  without  other  means,  serves  to  check  the  hemorrhage. 
This  is  through  reflex  action.  In  case  it  is  necessary  to  keep 
the  patient  in  bed,  an  ice  bag-  should  be  placed  over  the  pubes 
and  another  ice  bag  between  the  upper  surfaces  of  the  thighs. 
At  the  same  time  the  patient  should  be  given  a  hot  foot  bath  or 
leg  pack.  These  means  will  often  prove  so  effectual  that  pack- 
ing or  astringent  douches  are  unnecessary. 

Post-partum  hemorrhage,  if  occurring  immediately  after  the 
delivery  of  the  child  and  of  such  an  amount  as  to  prove  alarm- 
ing, should  be  immediately  treated  by  manual  stimulation  of  the 
uterus  through  the  abdominal  wall,  or  failing  in  this,  by  a  very 
hot  intra-uterine  douche.  If  the  hemorrhage  is  slight  or  not  so 
alarming  as  to  require  the  intra-uterine  douche,  the  patient  may 
be  given  a  very  hot  vaginal  douche  with  or  without  alum.  An 
ice  bag  may  be  used  over  the  pubes  and  replaced  after  the 
douche,  or  it  may  be  kept  in  place  without  interruption.  Any 
of  these  means  which  may  be  at  hand  should  be  applied  at  once, 
ergot  hypodermatically,  being  given  as  soon  as  possible,  provid- 
ing the  placenta  has  been  passed. 

Apoplexy 

The  early  treatment  of  cerebral  hemorrhage  should  consist  of 
an  ice  bag,  ice  cap,  or  large  ice  helmet  applied  to  the  head,  also 
ice  bags  or  compresses  placed  at  the  back  of  the  neck  and  over 
the  carotids.  The  limbs  should  be  kept  warm  by  hot-water 
bottles,  etc.  These  applications  may  be  left  in  place  until  there 
is  reason  to  believe  the  hemorrhage  has  been  checked.  Usually 
the  hemorrhage  does  not  continue  for  any  great  length  of  time, 
but  in  some  cases  almost  the  entire  cerebrum  may  become  in- 
filtrated with  blood  and  the  ventricles  filled.  Cold  applications, 
.if  used  promptly,  may  check  such  excessive  hemorrhage  as 
these.  Perfect  rest  is  an  absolute  essential  to  the  success  of 
any  form  of  treatment. 


CHAPTER   XXVII 
HYDROTHERAPY  IN  SURGERY 

T  TNDER  various  heads  we  have  already  considered  the  hydro- 
\*J  therapeutic  treatment  of  many  surgical  diseases.  The 
treatment  of  inflammatory  diseases,  many  of  which  require  sur- 
gical intervention,  has  been  discussed  under  its  proper  head. 
In  considering-  the  effects  of  pure  stimulants  and  under  treat- 
ment designed  to  relieve  pain,  still  other  surgical  conditions 
have  been  discussed.  There  remains  then  to  be  considered 
only  the  general  relation  of  hydrotherapy  to  operative  treatment 
and  the  care  of  the  patient.  For  convenience  the  subject  of 
hydrotherapy  in  surgery  may  be  divided  into  three  sections,  viz., 
preparatory  treatment,  immediate  care,  and  after-treatment. 

PREPARATORY  TREATMENT 

The  physical  condition  of  the  patient  at  the  time  of  operation 
has  a  great  deal  to  do  with  his  behavior  upon  the  operating 
table  and  with  the  comfort  and  rapidity  of  his  subsequent  con- 
valescence. Of  course  in  conditions  demanding  immediate 
attention  there  is  no  time  for  preliminary  treatment,  but  in  a 
very  large  number  of  surgical  diseases  it  is  neither  necessary 
nor  advisable  to  hurry  the  patient  to  the  operating  table.  This 
is  true  alike  of  many  inflammatory  and  many  non-inflammatory, 
conditions. 

In  considering  the  realm  of  physiologic  therapy  we  have 
already  mentioned  the  advisability  of  delay  in  the  operative 
treatment  of  certain  inflammations,  especially  of  pelvic  inflam- 
mations. Even  definite  inflammatory  states  largely  limited  to 
the  Fallopian  tube  or  the  ovary  are  usually  accompanied  by 
more  or  less  cellulitis.  Sometimes  an  inflammation  whose  most 


374  HYDROTHERAPY  IN  SURGERY 

marked  effects  are  in  the  cellular  tissue  involves  other  parts  so 
as  to  necessitate  removal  of  such  parts  or  mechanical  means  for 
their  release  from  plastic  exu dates  or  adhesions.  In  such  cases 
the  induration  and  residual  thickening  may  be  cleared  up  and 
quite  a  degree  of  the  normal  mobility  restored  as  has  been  dis- 
cussed under  the  treatment  of  the  chronic  stage  of  inflam- 
mations. These  results  may  be  so  thoroughly  accomplished 
that  the  remaining  conditions  will  necessitate  very  much  less 
operative  work  and  work  which  can  be  easily  and  rapidly  per- 
formed with  a  minimum  of  trauma  and  consequent  shock.  The 
resulting  shortening  of  the  period  of  anesthesia  is  also  a  dis- 
tinct advantage. 

The  stability  of  the  circulatory  system  is  still  another  factoi 
of  great  importance  in  surgery.  In  those  who  have  had  chronic 
inflammatory  or  suppurative  lesions  and  in  neurasthenics  and 
other  chronic  invalids  the  circulation  is  unbalanced  and  the  vaso- 
motors  fail  to  properly,  control  the  ebb  and  flow  of  circulatory 
changes.  The  anesthetic  and  the  operative  procedure  both  tend 
to  further  unbalance  the  circulation.  By  interference  with  the 
vasomotors  the  liability  to  undue  cooling  of  the  surface  and  to 
consequent  internal  congestion  are  much  increased.  Slight 
chilling  during  or  following  operation  may  produce  marked 
retrostasis  of  blood  to  the  interior,  and  thus  result  in  deepening 
an  already  existing  inflammation. 

The  preparation  of  the  patient  by  a  preliminary  two  or  three 
weeks'  course  of  vascular  hydriatic  tonics  will  guard  against 
these  dangers.  In  this  length  of  time  the  vitality  of  the  patient 
may  be  materially  raised.  Such  a  course  of  treatment  will  also 
result  in  ridding  the  system  of  the  accumulation  of  half  oxidized 
leucomaines  which  have  piled  up  during  the  preceding  invalid- 
ism.  Sweating  treatments  at  intervals  of  two  or  three  days 
may  also  be  necessary  to  still  further  enhance  elimination  and 
incidentally  to  promote  the  nutrition  and  healthy  activity  of  the 
skin. 

The  stimulation  of  kidney  activity  and  the  consequent  in- 
crease in  urinary  leucomaines  is  another  factor  in  the  general 
clearing-out  process.  Because  of  the  more  perfect  oxidation 
and  more  complete  elimination  of  waste  products,  the  alkalinity 


IMMEDIATE  CARE  375 

of  the  blood  is  increased.  Desirable  conditions  preparatory  to 
operation  are  also  produced  by  a  low  proteid  diet  and  the  free 
use  of  fruits.  Free  water  drinking  should  be  insisted  upon 
whenever  the  elimination  is  defective.  All  of  these  changes 
help  to  remove  toxemia — the  principal  cause  of  nerve  irritation 
— and  hence  aid  in  rest  or  in  nerve  tone  and  the  stability  of 
nerve  action.  The  increased  activity  of  the  circulation  and  the 
restoration  of  the  normal  reaction  of  the  blood  and  body  fluids 
are  large  factors  in  the  proper  healing  of  wounds.  The  physio- 
logic leucocytosis  and  consequently  heightened  phagocytic 
powers  of  the  white  blood  cells  which  result  from  hydriatic  tonics 
help  to  prevent  post-operative  infections,  whether  of  the  wound, 
of  the  respiratory  tract,  or  other  part  subject  to  unusual  con- 
ditions or  strain  during  operation. 

IMMEDIATE  CARE 

The  treatment  of  the  patient  during  and  immediately  follow- 
ing operation  resolves  itself  almost  entirely  into  the  use  of 
means  for  the  prevention  and  treatment  of  surgical  shock  and 
collapse.  The  keeping  of  all  the  vital  functions  in  as  nearly  a 
normal  condition  as  possible,  consistent  with  the  attainment  of 
surgical  anesthesia,  will  tend  to  prevent  the  occurrence  of  shock. 
The  use  of  ether  by  the  open  drop  method,  discarding,  unless 
specially  indicated,  all  mixing  of  anesthetics  or  the  hypodermic 
use  of  hypnotics  and  analgesics,  has  done  much  to  lessen  the 
occurrence  of  shock.  Of  course  where  the  occurrence  of  psychic 
shock  is  an  important  factor,  the  preliminary  use  of  hyoscine 
and  morphine  is  of  decided  advantage.  Let  the  ether  be  given 
slowly  at  the  start;  it  should  never  be  "pushed."  To  quite  an 
extent  this  will  obviate  the  occurrence  of  retching  and  vomit- 
ing. Where  the  alimentary  tract  is  not  the  objective  point  of 
the  operation,  the  giving  of  a  glass  of  cold  water  by  mouth,  im- 
mediately before  beginning  the  administration  of  ether,  will  be 
found  very  helpful  in  diminishing  the  tendency  to  vomiting. 
It  also  adds  that  much  water  to  the  body  fluids  to  aid  in  the 
subsequent  elimination  of  the  ether. 

The  skill  of  the  operator  in  proceeding  rapidly  yet  with  a 
minimum  of  trauma  and  hemorrhage  is  one  of  the  chief  factors 


376  HYDROTHERAPY  IN  SURGERY 

in  preventing"  surgical  shock.  In  this  connection1  W.  J.  Mayo 
has  said,  "We  hear  a  great  deal  about  shock  but  we  don't  see 
it.  We  sometimes  see  collapse  from  loss  of  blood." 

The  patient  should  not  be  weakened  by  repeated  catharsis. 
Limit  the  preparatory  use  of  cathartics  to  what  is  really  indi- 
cated, and  on  the  morning'  of  the  operation  finish  the  cleaning 
out  by  means  of  a  thorough  enema  of  tepid  or  warm  water. 
The  patient  should  reach  the  operating-  table  with  warm  feet 
and  hands,  and  during"  the  operation  the  extremities  should  be 
kept  warm  by  the  use  of  blanket  coverings  and,  if  necessary, 
hot-water  bottles  applied  outside  the  blanket.  The  use  of  a  hot 
foot  bath,  concluded  by  a  dash  of  cold  water,  given  just  before 
entering  the  operating  room,  may  do  much  to  prevent  or  limit 
splanchnic  engorgement. 

Surgical  Shock 

Until  the  researches  of  Geo.  W.  Crile  placed  the  subject  of  the 
causation  of  surgical  shock  upon  a  definite  experimental  basis, 
the  ideas  held  by  practicing  surgeons  were  most  various  and 
conflicting,  and  these  ideas  underwent  frequent  change.  If  one 
might  judge  of  these  ideas  by  the  therapy  employed  at  that 
time  (and  it  is  to  be  regretted  the  therapy  still  used  by  a  very 
large  number  of  surgeons),  one  would  unquestionably  say  that 
some  derangement  of  the  heart  itself  or  its  nerve  supply  has 
been  looked  upon  as  the  cause  of  surgical  shock.  That  the 
heart  is  not  primarily  at  fault  in  shock  has  been  proven  beyond 
question. 

Crile  makes  a  sharp  distinction  between  shock  and  collapse. 
Although  there  are  many  contributing  causes,  he  considers  that 
the  primary  and  principal  alteration  of  function  in  surgical  shock 
is  a  derangement  of  the  vasomo.tor  mechanism.  Collapse  is  due 
to  loss  of  body  fluid,  i.  e.,  to  hemorrhage.  It  may  also  be  clue 
to  direct  damage  to  the  heart  muscle,  the  respiratory  organs, 
or  the  nerves  of  either.  While  both  conditions  may  be  present 
in  a  given  case  at  the  same  time,  yet  they  are  essentially  dis- 
tinct entities.  These  are  the  views  generally  accepted  by  sur- 
geons today. 

1     Remarks  made  at  clinic  in  St.  Mary's  Hospital.  August  4.  1910. 


SURGICAL  SHOCK  377 

The  prevention  of  shock  is  fully  as  important  as  its  treatment, 
and  to  accomplish  either  result,  it  is  necessary  to  understand  the 
causes  of  the  disordered  function.  We  may,  therefore,  with 
profit  discuss  briefly  the  causes  contributing-  to  the  production 
of  surgical  shock.  Crile 2  enumerates  these  under  approximately 
six  heads.  They  are: — 

1.  Duration  of  operation. 

2.  Trauma. 

3.  Temperature. 

4.  Physical  condition  of  subject. 

5.  Anesthesia. 

6.  Hemorrhage. 

To  this  list  Yandell  Henderson 3  has  recently  added  another 
factor,  viz.,  acapnia.  The  term  is  used  to  designate  a  state  in 
which  there  is  a  deficiency  of  carbon  dioxide  in  the  blood.  In 
connection  with  these  seven  contributing-  causes  we  should  also 
discuss  the  vasomotor  and  the  cardiac  changes  present  in  shock. 

1.  Duration  of  Operation.     The  duration  of  an  operation  al- 
ways bears  a  direct  relation  to  the  occurrence  of  shock.     "  In 
all  the  experiments  in  which  pure  shock  was  produced,  it  wras 
found  that  a  considerable  time  was  required,  usually  half  an 
hour  or  more."       With  ether  as  the  anesthetic,  it  was  found 
that  dogs  would   survive   its  continuous  administration  for  a 
period  of  time  averaging  ten  hours. 

2.  Trauma.     As  has  been  mentioned,  trauma  is  one  of  the 
chief  external  causes  of  shock;     in  fact,  the  term,   "traumatic 
shock  "  is  frequently  used  interchangeably  with  surgical  shock. 
Trauma  of  nerve  centers,  nerve  trunks,  or  areas  richly  supplied 
with  nerves,  is  especially  liable  to  produce  shock.     Shock  is  also 
especially  likely  to  occur  on  exposure  of  the  brain,  pleura,  and 
peritoneum.       "Exposure  of  the  capacious  splanchnic  area  is 
attended  by  a  rapid  dilatation  of  the  splanchnic  vessels,  leading 
to  intense  congestion,  detracting-  thereby  a  dangerous  amount 
of  blood  from  the  somatic  circulation,  and  inducing-  a  rapidly 
declining-  blood  pressure." 

2  An  Experimental  Research  into  Surgical  Shock,  1899,  pp.  135—144. 

3  American  Journal  of  Physiology.  Vol.  XVII. 

4  Crile— Blood  Pressure  in  Surgery,  1903,  p.  298. 


S78  HYDROTHERAPY  IN  SURGERY 

3.  Temperature.     ' '  Contact  with  air  is  a  very  great  irritant 
to  local  tissues,  owing:  to  the  lowering:  of  local  temperature  and 
to  the  drying."     Animals  operated  in  a  cold  room  seem  to  suc- 
cumb more  readily  than  under  ordinary  warmth.     The  depres- 
sing; effects  of  cold    were   plainly  seen  when  cold    water   was 
brought  in  contact  with  the  intestines  or  when  an  intra-venous 
injection  of  cold  saline  solution  was  given.     The  effects  of  warm 
towels  applied  to  the  exposed  intestines  or  of  warm  saline  solu- 
tion in  the  abdomen  immediately  improved  the  respiration  and 
checked  declining  blood  pressure.      The  same  effect  of  cold  and 
warm  salines  was  noticed  on  the  brain  and  exposed  nerve  fibers. 

4.  Physical  Condition.     Individuals  in  impaired  health,  poorly 
nourished,  with  sluggish  circulation,  too  young  or  too  old,  are 
always  bad  subjects  for  operation.     We  have  elsewhere  men- 
tioned various  physical  conditions  which  contribute  to  the  occur- 
rence of  shock. 

5.  Anesthesia.     Over-anesthesia,  rapid  anesthesia  at  the  start, 
or  awkward  or  irregular  giving  of  an  anesthetic,  contribute  to 
the  production  of  shock.       Chloroform  requires  much  greater 
care  in  its  administration  than  ether.     Chloroform  is  more  toxic 
than  ether.     Chloroform  may  cause  sudden  cardiac  arrest;  and 
if  this  occurs,  it  is  usually  before  surgical  anesthesia  is  attained. 
In  this  respect  clinical  experience  coincides  with  experiment. 
For  these  reasons,  in  America,  the  majority  of  surgeons  prefer 
ether,  using  it  almost  exclusively. 

6.  Hemorrhage.      Loss  of  blood  always    predisposes    to    the 
occurrence  of  shock.     Hemorrhage  from  veins  is  productive  of 
more  immediate  harm  than  hemorrhage  from  arteries.     ' '  Hem- 
orrhage from    large  venous  trunks  caused  the  most  profound 
effect  upon  the  blood  pressure,  because  the  quantity  of  blood 
supplied  to  the  heart  was  immediately  diminished,  while,  if  the 
hemorrhage  was  arterial,  the  income  of  blood  was  not  so  sud- 
denly diminished.     The  output  of  the  heart  does  not  depend  at 
all  upon  the  height  of  the  arterial  pressure,  but  is  in  direct  pro- 
portion to  the  venous  pressure." 

7.  Acapnia,     Henderson  holds  that  carbon  dioxide  is  a  har- 
mone  or  chemical  regulator  of  respiration  and  that  the  phenom- 


SURGICAL  SHOCK  379 

ena  of  vasomotor  failure  in  shock  are  due  to  diminution  of  this 
gas  in  the  blood  and  body  tissues.  This,  he  claims,  is  broug-ht 
about  by  the  excessive  respiration  (and  consequent  over-ventil- 
ation of  the  blood)  caused  by  excitement,  fear,  pain,  or  forced 
breathing-.  Anesthetics  tend  to  prevent  shock  because  they 
diminish  the  excessive  respiration  due  to  pain.  The  habit  of 
covering  the  face  and  ether  mask  with  extra  layers  of  gauze, 
thus  causing  the  patient  to  rebreathe  some  of  his  own  carbon 
dioxide,  is  pointed  out  in  support  of  this  theory;  it  being  be- 
lieved that  this  practice  helps  to  maintain  more  perfect  narcosis 
and  raise  the  blood  content  of  carbon  dioxide.  Henderson  states 
that  ' '  skillful  anesthesia  consists  in  maintaining  the  threshold 
of  the  respiratory  center  for  carbon  dioxide  at  a  nearly  normal 
level,  and  in  avoiding  the  development  of  either  acapnia  or 
hypercapnia."  The  theory  seems  to  have  many  points  in  its 
favor;  it  needs  further  confirmation. 

Vasomotor  Changes.  The  experimental  data  upon  which  the 
vasomotor  theory  of  traumatic  shock  rests  is  altogether  too 
lengthy  to  be  given  here,  even  in  abstract.  It  has,  however, 
been  shown  that  in  surgical  shock  the  changes  in  blood  pressure 
are  entirely  independent  of  the  working  power  of  the  heart 
itself.  In  an  animal  reduced  to  a  state  of  shock,  the  heart  con- 
tinues to  beat  with  its  usual  force  as  long  as  it  is  supplied  with 
the  normal  amount  of  blood,  i.  e.,  as  long  as  it  is  furnished 
with  something  upon  which  to  expend  its  force. 

In  shock  the  vasomotors  are  at  first  over-excited  and  reveal 
symptoms  of  irregular,  disordered  action.  Vasomotor  curves  of 
blood  pressure  (Traube-Hering  curves)  become  rhythmic  over 
a  large  area  and  are  exaggerated.  Later,  after  some  exhaus- 
tion has  set  in,  vasomotor  effects  are  more  difficult  to  produce. 
Rhythmic  variations  finally  cease  and  changes  in  vascular  cali- 
bre end  in  maximal  vaso-dilatation.  In  animal  experiments, 
after  removal  of  the  stellate  ganglia,  stimulation  produced 
neither  a  rise  nor  a  fall.  In  drawing  conclusions  from  these 
phenomena,  Crile  says,  "These  several  results,  so  many  times 
obtained,  are  taken  as  an  evidence  of  a  vaso-constrictormechan- 
ism  or  action  and  a  vaso-dilator  mechanism  or  action,  or,  in 
other  words,  a  pressor  and  a  depressor  action;  and  that  the 
former  is  exhausted  more  readily  than  the  latter. ' ' 


S80  HYDROTHERAPY  IN  SURGERY 

"  In  a  number  of  vasomotor  phenomena  observed,  it  was 
apparent  that  there  are  regional  vasomotor  actions  quite  inde- 
pendent of  each  other. ' ' 

'  There  is  no  portion  of  the  circulatory  apparatus  so  delicate, 
whose  equilibrium  is  so  easily  disturbed,  and  whose  connection 
with  all  parts  of  the  body  is  so  minute  as  the  vasomotor.  A 
Priori,  it  would  be  the  most  readily  disturbed  as  well  as  the 
most  readily  exhausted  and  to  such  conclusions  do  our  observa- 
tions lead  us.  The  more  richly  supplied  with  vasomotor  nerves 
was  a  given  area,  the  more  rapidly  was  the  vasomotor  mechan- 
ism exhausted  when  such  area  was  subjected  to  injury.  This 
principle  was  abundantly  illustrated  in  the  experiments  upon 
the  splanchnic  area." 

The  experiments  of  Mall  show  that  the  splanchnic  nerves 
are  vein-nerves  and  control  this  large  and  spacious  vascular  area. 
Every  experiment  in  this  area  gave  evidence  of  the  dilatation  of 
the  vessels  controlled  by  these  nerves,  and  the  decline  of  the 
pressure  occurred  pari  passu  with  this  dilatation." 

Cardiac  Changes.  It  is  perfectly  evident,  as  remarked  by 
Crile,  that  "  The  heart  is  the  base  of  support  of  the  blood  pres- 
sure, and  any  interference  with  its  action  at  once  causes  marked 
changes  in  the  pressure."  The  heart  action  is  thus  directly 
influenced  by  venous  pressure  in  the  vena  cava.  Henderson 
places  special  emphasis  upon  this  latter  factor  in  discussing" 
what  he  has  called  the  ' '  veno-pressor ' '  mechanism.  The  recog- 
nition of  this  factor  in  cardiac  action  is,  however,  not  new.  It 
was  early  pointed  out  by  Crile  in  his  researches  into  the  causes 
of  altered  heart  action  (and  lowered  blood  pressure)  in  shock. 
He  says,  "  The  output  of  the  heart  is  in  direct  ratio  to  the  pres- 
sure of  the  vena  cava,  and  not  at  all  to  the  height  of  the  aortic 
blood  pressure.  The  venous  pressure,  then,  determines  the 
heart's  output  and  the  venous  pressure  is,  in  a  good  measure, 
dependent  upon  the  force  and  frequency  of  the  heart-beats,  to- 
gether with  the  necessary  vascular  tone,  which  is  under  the 
control  of  the  vasomotor  nerves. ' ' 

Through  vasomotor  exhaustion  the  blood  accumulates  in  the 
dilated  veins,  especially  those  of  the  splanchnic  area  which  are 
so  capacious.  There  has,  therefore,  occurred  "a  hemorrhage 


SURGICAL  SHOCK  381 

into  the  veins."  This  is  due  both  to  exhaustion  of  the  vaso- 
motors  of  the  veins  with  consequent  vaso- dilatation  and  to  the 
failure  of  the  arterioles  to  continue  their  pumping-  action.  This 
latter  is  likewise  a  result  of  vasomotor  failure.  The  results  of 
vein  engorgement  may  be  temporarily  overcome  by  pressure 
upon  the  abdomen  or  by  the  use  of  the  pneumatic  suit  devised 
by  Crile. 

In  regard  to  the  relation  of  intra-abdominal  tension  to  the 
veno-pressor  mechanism,  the  observations  recorded  by  Leonard 
Hill0  are  instructive.  "When  a  large  hutch  rabbit  is  held  for 
a  few  minutes  in  the  vertical  position  with  its  limbs  stretched 
out  and  head  uppermost,  it  may  become  unconscious  and  die 
from  cerebral  anemia.  The  blood  collects  in  the  large  flaccid 
abdomen,  the  animal  not  being  able  to  return  it  to  the  heart  by 
changing  its  posture.  It  struggles  to  maintain  a  circulation — 
cerebral  anemia  excites  convulsions  which  squeeze  the  blood 
from  the  limbs,  etc.,  into  the  heart — but  the  difficulty  in  face  of 
the  circulation  is  too  great  and  the  animal  dies.  A  wild  rabbit 
with  taut  abdomen  is  not  affected  in  this  way,  neither  is  a  cat 
or  dog,  but  a  goat  is  with  its  capacious  belly.  The  wild  rabbit 
can,  however,  be  brought  into  like  state  by  a  dose  of  chloral, 
and  so  can  a  dog:  by  chloroform  poisoning  or  by  bleeding.  The 
emotional  fainting  of  a  man  is  due  to  the  inhibition  of  the  nerv- 
ous system — a  neutralization  of  all  other  afferent  stimuli  by  one 
all-powerful  one — the  consequent  sudden  relaxation  of  muscular 
tone,  collapse  of  the  body  and  non-return  of  venous  blood  to  the 
heart.  The  horizontal  posture  or  compression  of  the  abdomen 
immediately  restores  from  syncope  the  rabbit  or  the  man." 

Pumping  Action  of  the  Blood-vessels.  The  control  or  main- 
tenance of  a  definite  vascular  calibre  is  not  the  only  work  of  the 
vasomotors;  vascular  activity  is  also  controlled  by  the  vasomotor 
centers.  Arterial  vascular  activity  helps  to  fill  the  veins  and 
venous  vascular  activity  helps  to  maintain  blood  pressure  in  the 
vena  cava.  While  laying  great  stress  upon  vascular  calibre  in 
its  effects  upon  the  work  of  the  heart,  nearly  all  observers 
entirely  ignore  vascular  activity.  To  illustrate  the  three  factors 


5    Further  Advances  in  Physiology,  p.  173. 


S82  HYDROTHERAPY  IN  SURGERY 

in  the  circulation,  Henderson6  employs  a  diagram  in  which  the 
arteries  are  represented  by  rigfid  tubes  and  changes  in  their 
calibre  as  equivalent  to  the  widening  or  narrowing  of  nozzle 
outlets.  While  this  may  illustrate  one  factor  in  the  work  of  the 
vasomotors,  it  entirely  overlooks  arterial  activity,  the  result  of 
which  it  is  impossible  to  conceive  of  as  illustrated  by  mere 
changes  in  resistance,  brought  about  by  the  widening  or  nar- 
rowing of  the  nozzles. 

In  conclusion  it  must,  therefore,  be  admitted  that  failure  of 
the  vasomotor  mechanism  is  the  chief  immediate  cause  of  sur- 
gical shock.  Neither  the  views  of  Porter  and  Quinby,  Seelig 
and  Lyon,  or  Yandell  Henderson  have  greatly  altered  this  con- 
ception of  the  pathologic  physiology  of  shock. 

The  Treatment  of  Shock 

There  is  no  better  place  than  the  operating  room  in  which  to 
demonstrate  the  prompt  tangible  results  obtained  by  the  use  of 
hydrotherapeutic  stimulation.  In  operations  upon  the  head, 
in  prolonged  or  extensive  abdominal  operations,  breast  ampu- 
tations, etc.,  and  in  other  cases  where  shock  is  likely  to  appear 
and  prove  dangerous,  the  success  attained  by  the  use  of  hydro- 
therapy  has,  in  our  hands,  been  uniformly  gratifying.  This 
has  also  been  the  experience  of  many  others  working  in  the 
association  of  medical  institutions  with  which  the  writer  is 
connected. 

The  plan  which  we  have  followed  is  very  similar  to  that  out- 
lined in  Chapter  XX  for  the  relief  of  acute  edema  of  the  lungs 
and  circulatory  crisis  in  valvular  heart  disease.  There  are 
certain  additional  features  to  be  taken  into  account,  so  that  it 
will  be  repeated  here  in  full.  The  principles  involved  in  the 
hydrotherapeutic  treatment  of  surgical  shock  are  neither  com- 
plicated nor  difficult  to  understand.  Their  intelligent  effective 
application,  however,  requires  a  knowledge  of  the  causation 
and  morbid  physiology  of  shock,  a  thorough  acquaintance  with 
the  methods  used  and  an  experience  in  their  use,  in  order  to 
know  how  to  adapt  the  means  to  the  case  in  hand  and  bring  re- 
sults where  these  results  are  difficult  to  obtain. 

6    American  Journal  of  Physiology,  Vol.  XXVII,  No.  I.  p.  159. 


SURGICAL  SHOCK  383 

The  vasomotor  failure  in  surgical  shock  can  be  and  is  met 
ideally  by  only  one  method  of  procedure,  viz.,  the  application 
of  cold  water  combined  with  friction.  If  hemorrhage  has 
occurred,  the  loss  of  fluid  must  be  met  by  the  introduction  of 
more  fluid.  Warm  saline  solution  may  be  given  by  hypoder- 
moclysis  or  by  proctoclysis  according-  to  the  urgency  of  the  case. 
It  is  usually  well  to  give  the  hypodermoclysis  while  the  patient 
is  on  the  operating  table  and  follow  it  with  saline  solution  by 
either  intermittant  protoclysis  or  by  continuous  proctoclysis 
after  the  method  of  Murphy,  begun  as  soon  as  the  patient  reaches 
his  room. 

When  shock  appears  during  the  operation,  the  patient  should 
be  treated  on  the  operating  table.  The  effectual  treatment  of 
shock  requires  the  attention  of  two  persons.  The  head  of  the 
table  should  be  lowered  to  counteract  cerebral  anemia.  On  the 
appearance  of  the  symptoms  of  shock,  immediately  place  the  pa- 
tient's feet  in  hot  water,  care  being  taken  that  the  water  is  not 
nearly  hot  enough  to  produce  a  burn;  or  better,  quickly  apply 
well  wrapped  fomentations  so  as  to  cover  both  feet  and  legs  to 
the  knees.  As  soon  as  the  parts  have  been  well  warmed  and  red- 
dened, remove  the  hot  applications  and  quickly  administer  to 
the  same  parts  a  cold  mitten  friction.  The  water  used  should 
be  ice  water  and  the  friction  most  vigorously  given.  The  mitts 
should  be  dipped  two  or  even  three  times,  another  attendant 
holding  the  limb  while  it  is  being  treated.  The  skin  is  now 
dried  and  rubbed  with  a  coarse  Turkish  towel  and  immediately 
covered  with  a  warm  dry  blanket.  The  thighs  should  be  treated 
in  the  same  manner,  also  the  arms.  While  this  is  being  done 
and  beginning  at  the  same  time  as  the  first  treatment  to  the 
limbs,  intense  and  quickly  alternating  hot  and  cold  applications 
should  be  made  to  the  anterior  surface  of  the  chest  and  espec- 
ally  over  the  precordia.  This  may  be  done  by  removing  the  ice 
bag  from  the  precordia,  which  should  have  been  placed  there 
when  the  pulse  first  became  unduly  rapid,  and  after  rubbing  the 
skin  briskly,  applying  a  very  hot  but  well  covered  fomentation. 
This  should  not  be  left  in  contact  with  the  skin  longer  than 
fifteen  or  thirty  seconds.  Next  rub  the  chest  with  a  flat  smooth 
piece  of  ice,  using  quick  to-and-fro  movements  and  wiping  away 


S84  HYDROTHERAPY  IN  SURGERY 

the  water  with  a  Turkish  towel.  After  this  another  fomentation 
is  applied,  again  followed  by  the  ice.  These  alternations  should 
be  repeated  three  or  four  times,  after  which  the  well  covered 
ice  bag  should  again  be  placed  over  the  heart. 

Wherever  there  is  any  hope  at  all  of  vasomotor  response, 
these  measures  result  in  prompt  rise  of  blood  pressure  and  as 
prompt  cardiac  response  to  the  increased  venopressure.  Where 
an  abdominal  operation  is  being  done,  it  is,  perhaps,  needless 
to  say  that  warm  gauze  napkins  should  be  applied  and,  if  feas- 
ible, some  pressure  exerted  upon  the  splanchnic  area  in  order 
to  more  quickly  send  the  blood  on  to  the  heart.  Rather  than 
leave  fluid  in  the  abdomen,  we  prefer  to  give  warm  saline  solu- 
tion per  rectum  even  while  the  patient  is  still  on  the  operating 
table. 

Unless  the  shock  is  very  severe  it  will  not  be  necessary  to  re- 
peat the  vasomotor  stimulation  short  of  thirty  or  forty  minutes. 
If  the  condition  of  the  patient  permits  and  repetition  of  the  vig- 
orous measures  outlined  above  is  not  really  needed,  it  will  be 
better  from  now  on  to  employ  milder  tonics  after  giving  some 
efficient  derivative  treatment. 

The  principle  of  this  plan  of  treating  shock  lies  in  the  effect 
of  brief  applications  of  heat  to  the  skin  surface  and  especially 
to  the  limbs,  in  order  to  warm  the  skin  and  aid  in  reducing  in- 
ternal congestion.  The  quickly  following  cold  friction  produces 
vigorous  stimulation  of  the  vasomotors,  so  that  the  blood  pres- 
sure rises  immediately.  The  vascular  condition  is  not  at  all 
comparable  with  that  produced  by  the  injection  of  adrenalin. 
It  is  not  a  stationary  vaso-constriction  that  results  from  a  cold 
friction,  but  a  vascular  activity — a  rapidly  alternating  dilatation 
and  contraction  of  the  blood-vessels.  This  is  a  true  pumping 
action  which  is  in  reality  only  a  heightening  of  the  normal  activ- 
ity of  the  blood-vessels. 

The  effect  of  different  temperatures  upon  the  blood  pressure 
has  already  been  discussed  in  Chapter  IX,  where  the  laws  de- 
duced by  Miiller  are  recorded.  Mliller's  studies  into  the  effects 
of  baths  on  blood  pressure,  were  carried  out  by  means  of  a 
Riva-Rocci  instrument  and  were  very  carefully  done  with  appar- 
ently every  precaution  taken.  Those  who  desire  to  study  fur- 


DRUG  TREATMENT  385 

ther  these  experiments  will  find  a  complete  consideration  of  the 
question  given  in  his  paper.7 

In  meeting  Henderson's  acapnia,  what  could  be  more  ideal 
than  raising-  the  carbon  dioxide  content  of  the  blood  and  tissues 
by  stimulating  its  production  from  the  tissues  themselves 
through  increased  oxidation?  That  this  can  be  efficiently  done 
by  thermic  and  mechanical  stimuli  and  results  very  promptly 
from  the  application  of  such  means,  has  already  been  shown  in 
Chapter  XII.  The  circulatory  stimulation  and  the  stimulation 
of  respiration  by  the  same  means  serve  to  maintain  the  proper 
per  cent  and  proportion  of  oxygen  and  carbon  dioxide  in  the 
blood. 

In  concluding  the  consideration  of  the  treatment  of  surgical 
shock,  other  than  a  practical  experience  in  the  satisfactory  re- 
sults attained,  we  could  offer  no  better  apology  for  the  pre- 
sentation of  so  simple  a  plan  for  its  treatment  than  to  summar- 
ize the  experimental  work  and  conclusions  therefrom,  reached 
by  recognized  authorities,  showing  the  failure  of  older  and  more 
pretentious  methods.  Those  who  wish  the  facts  at  first  hand 
will  find  the  results  of  the  most  exhaustive  and  conclusive 
studies  along  this  line  given  by  Doctor  Crile  in  his  monumental 
work,  "  Blood  Pressure  in  Surgery,"  8  which  appeared  in  1903. 

Alcohol.  '  The  immediate  effect  of  intravenous  administra- 
tion only  was  observed.  The  first  effect  usually  noticed  was  a 
decline  in  the  blood  pressure.  In  the  majority  of  such  instances 
a  compensatory  rise  followed;  in  a  number  of  instances  no 
change  in  the  blood  pressure  was  noted;  in  but  few  was  there  a 
rise.  The  average  length  of  the  stroke  of  the  manometer 
(height  of  pulsewave)  was  increased.  There  was  no  evidence 
that  the  heart  beat  more  forcibly.  In  animals  reduced  to  vary- 
ing degrees  of  surgical  shock,  the  usual  effect  of  an  average 
dose  of  alcohol  was  the  production  of  a  further  depression;  in 
smaller  doses  but  little  effect  was  noted,  while  in  larger  doses 
a  more  marked  decline  often  occurred.  In  few  instances  the 
administration  of  a  considerable  dose  in  deep  shock  was  followed 

7  Uber  den  Einfluss  von  Badern  und  Douchen  auf  den  Blutdriick  beim  Menschen— 
Deut.  Arch,  fur  klin.  Med.,  1902.  Volumn  LXXIV.  p.  316. 

8  Quotations  immediately  following,  unless  otherwise  credited,  are  from  this  work, 
pp.  261—300. 

25 


386  HYDROTHERAPY  IN  SURGERY 

by  almost  immediate  death.  In  a  number  of  experiments  the 
decline  in  the  blood  pressure  was  as  prompt  and  as  marked  as 
in  the  administration  of  the  amyl  nitrite  and  nitroglycerine. 
In  no  instance,  in  the  normal  animal,  did  death  immediately 
follow  the  largest  dose  of  alcohol;  the  more  profound  the  shock, 
the  more  marked  was  the  depressing  effect  of  alcohol.  In  a 
number  of  experiments  alcohol  was  given  prior  to  procedures 
intended  to  produce  shock.  It  is  not  certain  that  it  rendered 
the  animal  more  susceptible.  It  is  quite  certain  that  the  sus- 
ceptibility was  not  diminished." 

Nitroglycerine  and  Amyl  Nitrite.  ''  The  immediate  effect  of 
nitroglycerine  and  amyl  nitrite  upon  the  pulse  was  an  increase 
in  its  volume  and  a  decrease  in  frequency.  The  immediate 
effect  upon  the  respiration  varied.  At  times  there  was  a  slight 
increase,  more  frequently  a  slowing  of  respiration.  The 
immediate  effect  upon  the  blood  pressure  in  almost  every  in- 
stance was  a  fall.  The  decline  was  iisually  rapid.  There  were 
but  few  exceptions,  and  in  these  there  was  usually  no  effect. 
A  rise  was  rarely  observed.  In  the  latter  it  was  but  temporary 
and  was  usually  followed  by  a  fall.  The  descent  in  the  blood 
pressure  was  gradual  and  rather  rapid;  the  ascent,  more 
gradual." 

".In  the  experiments  in  which  the  animal  was  in  deep  shock, 
and  the  blood  pressure  was  gradually  falling,  there  was  no 
evidence  to  show  any  decrease  in  the  rapidity  of  the  decline. 
On  the  contrary,  as  nearly  as  could  be  estimated,  nitroglycerine 
distinctly  increased  the  rapidity  of  the  decline.  The  effect  of 
nitrite  of  amyl  was  in  every  respect  similar  to  that  of  nitro- 
glycerine. In  many  instances  the  heart  beat  irregularly  after 
the  injection.  On  the  whole,  nitroglycerine  and  amyl  nitrite 
increased  shock." 

.  Digitalis.  The  administration  of  digitalis  in  the  normal 
animal  produces  a  rise  of  blood  pressure  which  is  well  sustained. 
The  drug  is  very  likely  to  cause  over-stimulation  resulting 
in  sudden  cardiac  failure.  In  varying  degrees  of  shock,  digi- 
talis produces  a  less  marked  rise  of  blood  pressure  than  in  the 
normal  animal.  'The  respiration  when  at  all  affected  was 
cither  impaired  or  arrested.  Death  in  the  digitalis  experi- 


DRUG  TREATMENT  387 

ments,  even  in  those  in  which  the  dosage  was  only  therapeutic, 
was  usually  more  sudden  than  in  the  controls.  Although  the 
data  does  not  permit  positive  statements,  it  seemed  on  the 
average,  that  cases  of  shock  treated  by  digitalis  did  not  live  as 
long  as  the  controls.  It  may  certainly  be  stated  that  they  did 
not  live  longer  than  the  controls." 

Strychnine.  "in  the  majority  of  instances,  in  the  normal 
animal,  when  sufficient  amount  of  strychnine  was  given  to 
cause  an  increased  excitability  of  the  spinal  cord,  as  indicated 
by  heightened  reflexes  and  an  increased  muscular  tone,  a  rise 
in  blood  pressure  was  noted.  In  smaller  doses,  occasionally, 
a  slight  immediate  fall,  a  slight  immediate  rise,  or  later,  irregu- 
larities were  noted;  but  on  making  forty-eight  careful  measure- 
ments of  the  effects,  it  was  found  that  no  noteworthy  changes 
occurred." 

' '  In  forty-eight  experiments  it  was  found  that  strychnine  in 
therapeutic  doses  does  not  cause  a  rise  in  blood  pressure."  9 

"  The  stage  of  increased  excitability  above  mentioned  repre- 
sented the  border-land  between  the  dosage  without  effect  upon 
the  blood  pressure  and  that  of  maximum  effect.  When  more 
was  given  after  this  stage  had  been  reached,  convulsions  ap- 
peared, and  the  blood  pressure  rose  abruptly  and  high,  some- 
times even  more  than  doubling  the  normal.  The  curve  during 
the  convulsions  was  exceedingly  irregular,  and  continued  for 
some  time  above  the  normal,  exhibiting  a  secondary  rise  if 
later  convulsions  occurred." 

In  speaking  of  strychnine  experiments  in  which  both  vagi 
and  accelerantes  were  severed  and  curare  given,  Doctor  Crile 
says,  "On  repeating  the  dose,  a  period  was  soon  reached  in 
which  no  further  effect  was  noted.  After  each  dose,  when  the 
effect  had  worn  off,  the  blood  pressure  fell  to  a  lower  level  than 
it  was  before  the  injection  was  given,  until  finally  it  reached 
the  level,  usually  between  20  and  30  mm.,  which  was  not 
altered  by  an  additional  dosage." 

"  In  a  series  of  experiments  in  which  strychnine  was  given 
in  various  degrees  of  shock  in  such  dosage  as  to  cause  a  stimu- 
lation, the  effect  was  proportional  to  the  degree  of  shock,  i.  e., 


9    Crile— Detroit  Medical  Journal,  May,  1903,  p.  38. 


S88  HYDROTHERAPY  IN  SURGERY 

when  but  little  shock  was  present,  a  marked  effect  from  strych- 
nine was  obtained;  and  when  most  profound,  there  was  no 
effect.  In  the  intervening"  degrees  the  effects  were  propor- 
tional; but  after  giving  the  strychnine  the  animals,  not  yet  in 
complete  shock,  always  passed  into  a  deeper  degree  of  shock. 
In  any  degree  of  shock,  after  the  administration  of  a  therapeu- 
tic dose  of  strychnine,  the  animals  passed  into  deeper  shock. 
Later  in  the  research  it  was  found  that  the  most  convenient 
and  certain  method  of  producing  shock  for  experimental  pur- 
poses, is  by  the  administration  of  physiologic  doses  of  strych- 
nine. The  treatment  of  shock  then  by  therapeutic  doses  of 
strychnine  is  inert  and  physiologic  doses  dangerous. 

"  It  then  follows  that  treatment  of  shock  by  vasomotor  stimu- 
lants in  the  form  of  drugs  is  on  precisely  the  same  basis  as 
treatment  by  burning:  the  animal  or  crushing1  his  paws,  or  by 
subjecting  it  to  injury  or  operation,  it  would  seem  to  be  as 
reasonable  to  treat  strychnine  shock  by  administering  trauma- 
tism  as  traumatism  by  strychnine."  10 

The  more  recent  researches  of  Wallace  and  Pamment 12  on 
the  effects  of  strychnine  upon  blood  pressure  fully  agree  with 
those  of  Crile.  They  induced  low  blood  pressure  by  chloral, 
the  nitrites,  hemorrhage,  diphtheria  toxin,  chloroform,  and  by 
shock.  In  no  case,  except  chloral  poisoning,  did  the  use  of 
therapeutic  doses  of  strychnine  produce  a  rise  in  blood  pressure. 
Surgical  shock  is  an  exhaustion  of  the  vasomotor  center. 
Neither  the  heart  muscle,  nor  the  cardio-inhibitory  center,  nor 
the  cardio-accelerator  center,  nor  the  respiratory  center,  are 
other  than  secondarily  involved.  Collapse  is  due  to  a  suspen- 
sion of  the  function  of  the  cardiac  or  of  the  vasomotor  mechan- 
ism. In  shock  therapeutic  doses  of  strychnine  are  inert,  physio- 
logic doses  dangerous  or  fatal.  If  not  fatal,  increased  exhaus- 
tion follows.  There  is  no  practical  distinction  to  be  made 
between  external  stimulation  of  this  center  as  in  injuries  and 
operation,  and  internal  stimulation  by  vasomotor  stimulants, 
as  by  strychnine.  Each  in  sufficient  amount  produces  shock; 

10  Detroit  Medical  Journal.  May,  1903,  pp.  38.  39. 

11  Doctor  Crile  shows  sections  of  brain  tissue  revealing  degeneration  of  the  Purk- 
mje  cells  from  continuous  use  of  strychnine. 

12  Report  before   American  Society  for  the  Advancement  of  Clinical  Investigation. 
May  13,  1912.    Abstract  in  Journal  of  American  Medical  Association,  July  20,  1912,  p.  219. 


AFTER-TREATMENT  S89 

and  each,  with  equal  logic,  might  be  used  to  treat  the  shock 
produced  by  the    other.     Stimulants  of  the  vasomotor  center 
are    contraindicated.      Cardiac    stimulants   have   but  a  slig-ht 
rang-e    of   possible    usefulness,    and    may    be    injurious. 
Adrenalin  acts  upon  the  heart  and  blood-vessels.     It  raises  the 
blood  pressure  in  the  normal  animal,  in  every  degree  of  shock, 
when  the  medulla  is  cocainized,  and  in  the  decapitated  animal. 
It  is  rapidly  oxidized  by  the  solid  tissues  and  the  blood.     Its 
effects  are  fleeting:;  it  should  be  given  continuously."13     The 
effect  of  a  single  dose  of  adrenalin  lasts  from  two  to  four  min- 
utes.       '  The  longest  time  that  the  action  of  the  extract  on  the 
blood  pressure  was  prolonged  was  found  to  be  four  minutes. 
.   .   .     With  the  continuous  flow  of  the  -extract  into  the  vein, 
however,  the  pressure  was  kept  up  as  long-  as  the  flow  was  con- 
tinued, and  for  the  usual  time  after  it  had  been  discontinued.  " 

AFTER-TREATMENT 

Post-anesthetic  Infections.  The  question  of  how  best  to  pre- 
vent and  treat  post-anesthetic  pneumonia,  wound  infections, 
and  other  infections  following  operations  is  an  ever-present  one, 
and  to  the  surgeon  the  cause  of  no  little  anxiety  during  the  first 
three  or  four  days  of  the  after-care  of  the  patient. 

Modern  aseptic  technic  together  with  caution  in  regard  to 
unnecessary  traumatism  in  operating  and  in  regard  to  injury  of 
the  tissues  by  strong  antiseptics  or  the  prolonged  application  of 
antiseptics,  also  the  proper  use  of  serum  drainage,  has  reduced 
wound  infection  very  largely  to  a  matter  of  the  resistance  of  the 
patient's  tissues. 

We  have  already  shown  how  the  tissue  resistance  may  be  in- 
creased by  preparatory  treatment.  There  is,  however,  one 
cause  of  lowering  of  the  vital  resistance  which,  in  the  nature  of 
the  case,  can  not  be  eliminated.  This  factor  in  lowering  re- 
sistance is  nothing  else  than  the  anesthetic  itself.  It  results  in 
limiting  or  checking  for  the  time -being,  both  phagocytosis  and 
leucocytic  activity. 

After  anesthesia,  the  power  of  the  blood  to  destroy  pathogenic 
bacteria  is  markedly  reduced.  "  In  fact,  the  members  of  the 

13    Detroit  Medical  Journal,  May  1903.  p.  45. 


S90  HYDROTHERAPY  IN  SURGERY 

entire  group  of  alcohol,  ether,  and  chloroform  reduce  the  power 
of  the  blood  to  combat  bacteria;  the  state  of  a  man  after  a  long- 
anesthesia  is  comparable  to  that  of  an  alcoholic  with  bronchitis 
who  has  been  sleeping  off  an  overdose  of  alcohol  in  a  door-way 
or  a  freight  car. 

' '  So  important  a  subject  is  this  post-operative  pneumonia 
that  much  interest  attaches  to  the  recent  studies  of  Graham  on 
anesthesia  and  the  bactericidal  powers  of  the  blood.  Accord- 
ing to  these  experiments,  it  is  not  the  power  which  serum  itself 
has  of  destroying  bacteria  through  bacteriolysis  which  is 
reduced  by  anesthetics,  but  the  destruction  of  bacteria  by 
phagocytosis  is  greatly  reduced.  Now  it  so  happens  that  the 
organisms  which  we  have  to  fear  in  surgery,  the  pneumococcus 
and  the  pus  cocci,  are  destroyed  chiefly  through  phagocytosis 
and  not  by  bacteriolysis,  which  gives  added  importance  to  this 
depressing  effect  on  the  bactericidal  powers  of  the  blood. 
Apparently  ether,  the  anesthetic  which  Graham  has  studied, 
reduces  both  the  efficiency  of  the  opsonins  and  the  power  of  the 
leucocytes  to  take  up  the  sensitized  bacteria;  these  effects  can 
be  seen  both  in  the  blood  of  the  patients  or  animals  after  anes- 
thesia, and  in  drawn  normal  blood  treated  with  ether  in  the  test 
tube.  The  action  of  the  ether  is  not  permanent,  the  opsonic 
power  being  restored  promptly  on  removal  of  the  ether." 

Dr.  C.  Achard  has  recently  called  attention  to  these  facts  and 
their  importance  in  the  causation  of  certain  post-operative 
accidents  in  a  paper15  read  before  the  Academic  de  Medecine. 

The  use  of  morphine  as  an  anesthetic  aid,  even  where  defi- 
nitely indicated,  must  of  necessity  be  an  added  source  of  danger 
from  infections.  L.  Reynolds  16  has  emphasized  this  fact  and 
called  attention  to  the  disadvantage  in  using  morphine. 

"  From  experiments  performed  by  him,  Reynolds  concludes 
that  morphine  exerts  a  marked  influence  on  the  leucocytes. 
Not  only  does  it  check  diapedesis,  but  phagocytosis  is  dimin- 
ished in  a  marked  degree.  The  growth  of  bacteria,  on  the 
other  hand,  is  not  appreciably  affected.  What  bearing  has  this 

14  Editorial   in  Journal   of  American   Medical    Association.   February   18,    1911.  also 
March  26,  1910,  pp.  1043—1045. 

15  April.  1910. 

16  London  Lancet,  February  26.  1910. 


AFTER-  TREA  TMENT  391 

on  the  practice  of  medicine  in  surgery?  It  is  probable  that 
in  most  surgical  operations  a  certain  number  of  pathogenic 
organisms  gain  entrance  to  the  wound,  however  carefully 
asepsis  be  observed.  The  further  history  of  the  case  turns  on 
this  point.  Will  the  phagocytes  be  able  to  destroy  these  bac- 
teria before  the  latter  have  multiplied  sufficiently  to  gain  the 
upper  hand?  If  morphine  temporarily  paralyzes  the  activity  of 
the  phagocytes,  if  this  drug  be  given,  time  is  lost  during  which 
the  bacteria  multiply.  When  the  narcosis  passes  off,  the  phago- 
cytes may  be  unable  to  destroy  the  bacteria  on  account  of  their 
number  and  the  paralyzing  effect  of  the  toxins  produced  by 
them;  in  fact  by  giving  the  morphine  the  chances  of  sepsis  have 
been  increased."  17 

In  1903  Snel 18-  reported  the  results  of  experiments  with 
guinea  pigs  relative  to  the  effects  of  ether,  chloral,  and  alcohol 
on  immunity.  These  drugs  temporarily  suspend  immunity, 
the  longer  the  period  of  anesthesia  the  shorter  being  the  pro- 
cess of  infection.  In  1904  Rubin l9  reported  the  same  results 
from  alcohol,  ether,  and  chloroform.  These  agents  depress 
leucocytosis  and  phagocytosis  and  even  where  a  high  leucocyte 
count  was  present  before  death,  the  marked  diminution  of  the 
phagocytic  power  of  the  leucocytes  accounted  for  the  fatal 
result. 

It  thus  appears  plain  that  the  use  of  mixed  anesthesia  is  not 
to  be  encouraged  unless  very  definitely  indicated.  The  use  of 
morphine  may  be  necessary  in  operations  for  hyperthyroidism 
and  in  a  few  other  conditions,  but  unless  there  are  good  reasons 
for  its  administration  in  other  conditions,  it  should  not  be 
given. 

In  the  treatment  and  prevention  of  post-anesthetic  infections, 
there  are  three  things  to  be  accomplished.  These  are:  First, 
the  rapid  elimination  of  the  ether;  second,  the  raising  of  the 
phagocytic  activity;  and  third,  the  reduction  of  local  con- 
gestions. 

Rapid  elimination  of  ether  is  best  accomplished  by  the  giving 
of  much  water  immediately  following  the  operation.  The  rou- 

17  Abstract  of  article  by  Reynolds  in  Journal  of  American  Medical  Association. 

18  Berliner  klinische  Wochenschrift,  1903,  No.  10,  pp.  .212—214. 

19  Journal  of  Infectious  Diseases.  1904,  May  30,  pp.  425—444. 


S9»  HYDROTHERAPY  IN  SURGERY 

tine  use  of  gastric  lavage  before  the  patient  recovers  from  the 
anesthetic  is  one  of  the  best  means  for  getting-  rid  of  the  ether, 
preventing  vomiting,  and  the  occasional  occurrence  of  acute 
gastric  dilatation.  The  use  of  the  saline  enema  is  specially 
.helpful.  In  giving  continuous  proctoclysis,  after  the  volume  of 
the  circulating  fluid  has  reached  normal,  the  added  fluid  is 
eliminated  by  the  kidneys  as  fast  as  it  is  absorbed. 

This  same  measure  also  helps  in  decreasing  the  danger  from 
post-operative  nephritis.  As  soon  as  the  patient  is  out  from 
under  the  anesthetic,  copious  water  drinking  should  be  insisted 
upon.  It  will  not  be  likely  to  cause  vomiting,  and  if  it  should 
seem  to  have  this  effect,  gastric  lavage  may  be  resorted  to  and 
continued  until  the  stomach  has  been  washed  clean.  Sips  of 
very  hot  water  or  swallowing  bits  of  ice  will  then  relieve  the 
trouble,  and  in  a  little  while  the  free  use  of  water  may  be 
continued. 

An  active  circulation  will  also  aid  in  the  elimination  of  the 
ether;  and  this,  together  with  the  stimulation  of  leucocytic 
activity,  may  be  accomplished  by  the  use  of  the  cold  mitten 
friction  with  the  ice  bag  to  the  heart.  Both  these  measures 
increase  the  depth  of  respiration  and  the  volume  of  tidal  air  so 
that  more  thorough  ventilation  occurs. 

Considerable  importance  attaches  to  the  prevention  of  internal 
congestions  and  visceral  stasis  of  blood,  especially  in  the  lungs 
and  about  the  site  of  operation.  As  a  means  to  this  end,  we 
have  adopted  as  almost  a  matter  of  routine  the  use  of  the  hot 
foot  bath,  the  hot  leg  pack,  or  electro-thermal  pack  to  the  legs 
as  soon  as  convenient,  immediately  following  the  operation.  If 
the  hot  leg  pack  is  used,  a  dry  blanket  should  be  placed  next  to 
the  skin.  A  well  covered  ice  bag  is  placed  over  the  heart  at 
the  same  time.  The  treatment  is  continued  until  the  limbs  are 
well  reddened  and  should  be  concluded  by  a  cold  mitten  friction 
to  the  same  skin  surface.  This  procedure  will  usually  last 
about  thirty  minutes.  It  will  probably  not  be  necessary  in 
ordinary  cases  to  repeat  it  for  several  hours  or  until  the  next 
day. 

Transient  albuminuria  does  not  usually  require  any  special 
treatment.  If  albumen  and  casts  appear  in  the  urine,  derivative 


A  FTER-  TREA  TMENT  393 

treatment  is  indicated  and  free  perspiration  should  be  encour- 
aged. Sweating  should  never  continue  long:  at  a  time. 

If  pneumonia  occurs,  use  derivative  measures  and  apply  the 
cold  coil  or  cold  compress  to  the  chest.  These  should  be 
occasionally  interrupted  by  the  application  of  a  fomentation  or 
the  revulsive  compress  used.  The  ice  bag:  to  the  heart  and  the 
cold  mitten  friction  are  also  of  great  service  in  treating  post- 
operative pneumonia.  For  further  details  see  article  on  pneu- 
monia in  Chapter  XIX. 

After  gall-bladder,  appendix,  tubal,  and  some  other  abdomi- 
nal operations,  a  right  sided,  diaphragmatic  and  consequently 
much  hidden  pleurisy  may  appear.  It  is  usually  not  severe 
and  will  respond  to  the  usual  treatment. 


T 


CHAPTER   XXVIII 

INSANITY  AND  DRUG  ADDICTIONS 

JESSIE  H.  SIMPSON,   M.  D. 

THE  INSANE 

HE  treatment  of  the  insane  is  still  in  the  involutional 
period  to  a  more  marked  degree  than  any  other  line  of 
therapy,  and  the  introduction  of  hydrotherapeutic  measures  has 
done  much  to  alleviate  this  unfortunate  class ,  tending-  as  it  does 
to  eliminate  the  use  of  hypnotic  drugs  and  mechanical  restraint. 

In  dealing  with  the  insane  two  very  different  lines  of  symp- 
toms are  encountered,  so  that  for  the  purpose  of  this  chapter 
we  will  divide  them  into  excited  and  depressed  cases  regardless 
of  mental  diagnosis. 

Many  of  these  cases  when  first  coming  under  treatment  show 
marked  symptoms  of  autotoxemia,  which  suggest  colonic  flush- 
ings, and  measures  calculated  to  stimulate  skin  elimination 
with  free  drinking  of  water,  and  indeed  all  hydrotherapeutic 
measures  should  be  preceded  by  thorough  cleansing  of  the  in- 
testinal tract. 

The  excited  cases,  whether  manic-depressive,  paretics,  seniles, 
dementia  prsecox,  or  other,  presenting  the  .symptoms  of  sleep- 
lessness, hyperactivity,  logorrhea  perhaps  destructive,  profane, 
violent,  and  resistive,  require  sedative  treatment,  which  must 
be  adapted  to  the  condition  of  the  individual  patient.  Here 
two  methods  have  proven  very  helpful, — the  continuous  flowing 
bath  and  the  wet  pack. 

The  continuous  flowing  bath  (Plate  XX.)  requires  a  special 
tub  six  feet  long,  which  is  supplied  with  a  large  overflow  vent 
near  the  top  and  a  large  outflow,  so  that  the  tub  can  be  emptied 
and  cleaned  quickly.  The  inflow  may  consist  of  one  large 

(394) 


THE  INSANE  395 

opening:  at  the  head,  or  of  several  small  opening's  around  the 
sides,  in  either  case  connected  directly  with  a  mixing-  chamber 
which  is  supplied  with  a  thermometer.  A  continuous  supply  of 
hot  water  must  be  assured.  The  water  is  regulated  to  the 
desired  temperature  in  the  mixing  chamber  before  it  is  turned 
into  the  tub.  When  the  tub  is  full  and  overflowing  the  quantity 
is  reduced  to  a  gentle  stream.  The  patient  rests  upon  a  canvas 
cot  which  fits  inside  the  tub,  or  upon  a  hammock  which  swings 
from  its  margin,  is  protected  by  a  convas  cover  and  provided 
with  a  rubber  air  pillow.  An  ice  turban  should  be  placed  upon 
his  head  and  he  should  be  given  cold  water  plentifully  to 
drink. 

An  attendant  must  watch  the  insane  patient  constantly  while 
in  the  bath  to  see  that  no  harm  comes  to  him.  It  is  well  to 
keep  a  bath  thermometer  in  the  tub  and  consult  it  frequently, 
not  relying  wholly  upon  the  thermometer  in  connection  with 
the  mixing  chamber.  The  usual  temperature  of  these  baths 
is  98°  F. 

Very  excited  and  violent  patients  are  difficult  to  handle  and 
should  be  placed  in  a  dry  sheet  or  blanket  pack,  securely 
pinned  about  them  and  then  placed  in  the  tub.  The  continuous 
bath  may  be  administered  for  hours  or  days.  In  the  latter  case 
the  patient  must  be  removed  once  or  twice  in  the  twenty-four 
hours,  the  bowels  given  proper  attention,  and  the  skin  annointed 
with  olive  oil  or  other  unguent  to  prevent  too  great  maceration. 

Wet  sheet  or  blanket  packs  (Plate  XXL}  have  many  advan- 
tages in  as  much  as  they  can  be  administered  in  either  institu- 
tional or  private  practice  and  to  maniacal  patients.  They  may 
be  used  cold,  neutral,  or  hot.  Authorities  differ  as  to  which 
gives  the  most  sedative  effect.  However,  good  results  can  be 
obtained  at  any  temperature. 

Dr.  Rabekah  B.  Wright,  whose  experience  in  this  work  has 
been  extensive,  recommends  cold  packs,  "the  colder  the  better 
(40° — 65°)  in  maniacal  cases."  Packs  should  be  administered 
in  a  warm  room  and  ice  applied  to  the  head,  and  it  is  well  to  pin 
the  pack  so  that  the  patient  may  not  become  exposed.  They 
may  be  continued  from  one  hour  to  several  hours.  If  the  pa- 
tient becomes  quiet  and  sleeps,  he  may  remain  in  the  pack  all 


S96  DRUG  HABITUES 

night,  or  he  may  be  removed  at  any  time  when  the  restraint 
becomes  tiresome.  If,  however,  he  docs  not  become  quiet  in 
an  hour,  he  should  be  removed  from  the  pack  and  sponged  and 
dried,  as  under  these  conditions  the  pack  may  become  heating- 
and  send  his  temperature  up  to  an  alarming"  degree.  Debili- 
tated patients,  or  those  suffering'  from  arterio-sclerosis,  should 
not  receive  this  treatment,  the  continuous  bath  being-  preferable. 
Depressed  cases  require  tonic  treatments.  Of  these  the  salt 
glow  holds  a  leading-  place;  hot  and  cold  to  the  spine  followed 
by  the  needle  spray  and  fan  douche;  fomentations  to  the  liver, 
if  that  org-an  is  inactive,  followed  by  the  spray  and  douche;  the 
electric  lig"ht  or  hot  air  bath  followed  by  the  spray  and  douche 
are  all  useful,  tog-ether  with  liberal  feeding-  and  good  hyg-iene. 

DRUG  HABITUES 

Morphine,  Cocaine,  Etc.  Whether  immediate  or  gradual 
withdrawal  of  the  drug-  is  practiced  or  whatever  method  of  cure 
is  used,  hydrotherapy  is  a  useful  adjunct.  During-  the  early 
abstenance  symptoms,  when  the  patient  is  suffering  from  nausea, 
diarrhea,  shifting-  pains,  and  great  restlessness  and  sleepless- 
ness, the  continuous  bath  administered  for  one-half  hour  to  two 
or  three  hours  at  a  time  relieves  the  symptoms  and  frequently 
induces  sleep.  Sometimes  a  wet  pack  will  bring  sleep,  fomen- 
tations will  relieve  the  pains  when  they  are  more  localized, 
and  an  ice  cap  at  the  pit  of  the  stomach  will  freq^^ently  re- 
lieve the  nausea. 

After  these  early  symptoms  have  been  relieved,  elimination 
can  be  stimulated  and  the  patient  toned  up  generally  by  the  use 
of  electric  Hg-ht  or  hot  air  baths  followed  by  the  spray  and 
douche. 

Alcohol.  In  delirium  tremens  the  continuous  bath  is  indi- 
cated tog-ether  with  other  measures.  If  this  is  not  available, 
hot  packs  may  be  used.  For  the  later  effects  of  alcohol,  elim- 
ination, and  tonic  treatments  are  needed,  the  electric  light  and 
hot  air  baths  holding-  a  leading-  place,  each  to  be  followed  by  the 
spray  and  douche. 


PLATE  XX.     The  continuous  flowing  bath  as  installed  at  the 
Southern  California  State  Hospital. 


PLATE  XXI.    The  wet  sheet  pack   and  pack  tables  at  the 
Southern  California  State  Hospital. 


PART  III 

TECHNIQUE  OF  HYDROTHERAPY 


CLASSIFICATION  OF  PROCEDURES 

BECAUSE  of  similarity  in  technique  and  for  convenience  of 
description,  we  have  classified  the  procedures  of  hydro- 
therapy  under  the  following:  thirteen  heads: — 

1.  Local  Applications  of  Heat.    These  include  localized  appli- 
cations of  heat  to  such  areas  as  the  abdomen,  spine,  chest,  or  a 
joint.     Examples:     The  fomentation,  hot-water  bottle,  radiant 
heat. 

2.  Local  Applications   of   Cold.      These     are     circumscribed 
applications  of  cold   to  such  areas  as  those   mentioned  above. 
Examples:     Ice  bag",  cold  water  coil. 

3.  ff eating  Compresses.     A  heating"  compress  is  a  local  appli- 
cation of  moist  heat  made  by  applying-  next  to  the  skin  a  cloth 
wrung"   from    cold  water,    and   so  covered  with  flannel  or  an 
impervious  covering-  as  to  cause  an  accumulation  of  body  heat. 
Examples:     Moist  chest  pack,  moist  abdominal  g-irdle,  heating 
compress  to  throat. 

4.  Poultices.     A  poultice  is  an  application  of  moist  heat  made 
by  means  of  a  semisolid  mixture  of  various  substances,  and 
applied  to  the  body  while  hot.     Examples:     Flaxseed,  clay  and 
glycerine,  charcoal. 

5.  Tonic  Frictions.     A  tonic  friction  is  an  application  of  cold 
water  so  combined  with  friction  as  to  produce  stimulating  or 
tonic  effects.     Examples:     Cold  mitten  friction,  wet  sheet  rub. 

6.  Sponging-.     Sponging  or  ablution  consists  in  the  applica- 
tion of  a  liquid  by  means  of  a  sponge,  a  cloth,  or  the  bare  hand, 
in  which  the  chief  effect  is  derived  from  the  liquid  applied. 
Examples:     Cold  water  sponging,  alcohol  rub,  soap  wash. 

(397) 


S98  TECHNIQUE 

7.  Rubs  and  Frictions.  These  are  procedures  in  which  the 
chief  effect  is  derived  from  friction  with  the  bare  hands. 
Examples:  Centripetal  friction,  oil  rub. 

S.  Baths.  Under  this  heading  are  included  various  local 
and  general  procedures  in  which  the  body  is  immersed  in  water, 
light,  heated  air,  or  vapor.  Examples:  Tub  bath,  foot  bath, 
electric  light  or  Russian  baths. 

9.  Shampoos.  The  term  shampoo  applies  to  local  or  general 
cleansing  measures  by  means  of  soap  and  water.  (It  is  some- 
times applied  to  massage).  Examples:  Swedish  shampoo, 
Turkish  shampoo. 

10.  Packs.     A  pack  is  a  procedure   in  which  a  considerable 
portion  of  the  body  is  enveloped  in  wet  sheets  or  blankets  for 
therapeutic  purposes.     Examples:     Hot  blanket  pack,  hot  hip 
and  leg  pack,  wet  sheet  pack. 

11.  Sprays  and  Douches.     A  spray  or  douche  consists  in  the 
projection  of  one  or  more  streams  of  water  against  the  body. 
Examples:     Shower  bath,  needle  spray,  pail  pour,  hot  and  cold 
douche. 

12.  Enemata.     An    enema    is    an  injection    of   fluid    into  the 
lower   bowel.       Examples:      Warm    enema,    rectal    irrigation, 
coloclyster,  oil  enema,  starch  enema. 

13.  Vaginal  Douches.     The    vaginal    douche    consists    in    the 
flushing   or    irrigating   of   the    vaginal    cavity    with    a    fluid. 
Examples:     Hot  vaginal  irrigation,  disinfectant  douches,  styp- 
tic douche. 

GLOSSARY  OF  TERMS 

The  terms  listed  below  are  used  to  designate  the  various 
physiologic  or  therapeutic  effects  of  water  and  in  the  descrip- 
tion of  methods.  Some  of  these  have  applied  meanings  slightly 
different  from  that  ordinarily  given. 

1.  Tonic.     A  tonic  effect  is  one  in  which  vital  activities  are 
increased  so  as  to  restore  the  body  to  a  normal  tone  or  condition. 
The  nutrition,  circulation,  and  other  body  functions  are  pro- 
moted. 

2.  Pure  Stimulant.     A  stimulant  arouses  the  body  to  unusual 
activities.     It  may  be  compared  to  a  whip  and  is  used  chiefly 


GLOSSARY  OF  TERMS  399 

in  emergencies.  Like  a  tonic  it  increases  vital  activities,  but 
to  a  much  greater  degree.  Between  a  pure  stimulant  and  a 
tonic  there  are  various  gradations  which  might  be  designated 
as  mild  stimulant,  extreme  tonic,  etc. 

3.  Sedative.      A  sedative   or  calmative  agent  is  one    which 
lessens  vital  activity  and  is  conducive  to  relaxation  and  rest. 

4.  Antispasmodic.     The    relaxing   of   spasm  or  relieving   of 
convulsions. 

5.  Depressant.     A  depressant  effect  is  one  in  which  heightened 
or  normal  body  activities  are  decreased  to  a  marked  degree. 
Such  an  effect  is  desirable  only  where  a  function  is  greatly 
overactive. 

6.  Anodyne.     An  anodyne  effect  refers  to  the  relief  of  pain. 

7.  Spoliative.     A  spoliative  treatment  is  one  which  increases 
the  oxidation  and  breaking  down  (catabolism)  of  tissue;  tend- 
ing to  reduce  weight. 

8.  Diaphoretic.     The  production  of  sweating.     An  agent  that 
produces   sweating  is   said  to  have  a   diaphoretic  or  sudorific 
effect. 

9.  Diuresis.     Increased  excretion  of  urine. 

10.  Eliminative.     An  eliminative  effect  consists  in  promoting 
and    hastening   excretion    from   the    kidneys    (diuresis),    skin 
(diaphoresis),  and  lungs. 

11.  Depletion.     Depletion  is   the   lessening  of  the  amount  of 
blood  in  a  given  part, — practically  it  is  the  reduction  of  con- 
gestion. 

12.  Derivative.     Derivation  is  the  drawing  of  blood  or  lymph 
from  one  part  of  the  body  by  increasing  the  amount  in  another 
part.     The  term  depletion  is  also  applied  to  this  process,  but 
refers  particularly  to  the  result  produced. 

13.  Fluxion.      Fluxion    consists    in    greatly    increasing    the 
rapidity  of  the  blood  current  in  a  particular  part.     It  is  the 
production  of  active  or  arterial  hyperemia. 

14.  Revulsive.     A  term    used    to  designate  a  treatment   con- 
sisting of  a  single  prolonged  application  of  heat  followed  by  a 
single    very   brief   application  of  cold.     This  meaning  is  not 


400  TECHNIQUE 

strictly  adhered  to  as  the  term  is  also  used  where  three  applica- 
tions of  such  proportionate  duration  are  made. 

15.  Alternate.     The  expression  ' '  alternate  hot  and  cold  ' '   is 
used  in  this  text  to  describe  treatments  in  which  the  duration 
of  the  cold  application  is  from  one-fourth  to  one-half  that  of  the 
heat  (in  a  few  cases  equal  with  it)  and  in  which  three  or  more 
changes  from  heat  to  cold  are  made. 

16.  Antipyretic.      The  lowering:   of   the  body  temperature  in 
fever. 

17.  Refrigerant.     Relieving;  of  thirst  and  restoring;  the  alka- 
linity of  the  blood  by  such  means  as  free  water  drinking-  and 
the  use  of  fruit  juices. 

LOCAL  APPLICATIONS  OF  HEAT 
Fomentations — Fo. 

A  fomentation  is  a  local  application  of  moist  heat  by  means 
of  cloths  wrung;  from  hot  water. 

(a)  Articles  Necessary.  In  well  equipped  treatment  rooms 
the  fomentation  tank  should  be  so  arranged  that  the  water  from 
which  the  fomentations  are  to  be  wrung  can  be  heated  by  live 
steam  passed  into  the  water  through  a  coil.  When  properly 
arranged  the  escape  of  steam  from  this  coil  into  the  water  will 
be  noiseless  and  cause  the  water  to  boil  more  vigorously  than 
over  a  fire.  The  outlet  of  the  tank  should  be  controlled  by  a 
valve,  never  by  a  plug.  A  wringer  with  extra  long  rollers 
should  be  clamped  to  the  side  or  end  of  the  tank  and  a  table 
placed  immediately  beyond  the  wringer  on  which  the  fomenta- 
tions may  be  wrapped  (Plate  XXIII.}.  The  fomentations 
will  be  hotter  if  heated  directly  by  live  steam.  Special  steam 
boxes  (Plates  XXIV  and  XXV.)  maybe  provided  for  this  pur- 
pose or  live  steam  passed  into  fomentation  cloths  packed  in  a 
pail.  If  treatment  is  given  at  the  patient's  residence  a  boiler 
or  pail  of  hot  water  may  be  used.  In  an  institution  it  is  rarely 
necessary  to  carry  a  pail  of  hot  water  to  the  patient's  room,  as 
the  fomentations ,  will  be  hotter  if  prepared  in  the  treatment 
rooms  and  packed  in  a  pail  in  the  manner  described  below. 
The  nurse  should  also  be  provided  with  a  set  of  six  fomentation 


LOCAL  APPLICATIONS  OF  HEAT  1,01 

cloths,  two  Turkish  towels  for  drying  the  patient,  one  large 
cotton  sheet  for  covering-  the  patient,  a  bowl  of  cold  water  or 
ice  water,  and  one  or  two  hand  towels.  An  oil  cloth  and  extra 
sheets  and  towels  will  be  necessary  to  protect  the  bedding.  If 
the  treatment  is  to  be  given  in  a  patient's  room,  provide  a  grass 
mat  on  which  the  pail  of  fomentations  or  hot  water  may  be 
placed.  If  the  pail  is  placed  on  a  carpet,  a  newspaper  may  be 
all  that  is  required.  When  the  pail  is  set  on  a  chair  with  a 
newspaper  under  it  the  heat  causes  the  paper  to  stick  to  the 
varnish. 

(£)  The  Patient.  All  clothing  should  be  removed.  If  the 
clothing  is  not  removed,  then  bare  a  larger  area  than  the  part 
to  be  treated  and  thoroughly  protect  the  clothing  by  thick  Turk- 
ish towels.  See  that  the  feet  are  warm  and  kept  so  during 
treatment.  If  they  are  cold,  a  hot  foot  bath  should  be  given, 
or  hot- water  bottles  applied.  The  hot  foot  bath  is  much  more 
effective  than  any  other  means  of  warming  the  feet. 

In  giving  fomentations  to  a  bed  patient  great  ca"re  should  be 
exercised  to  avoid  steaming  the  bedding,  as  a  patient  may  easily 
take  cold  because  of  bed  linen  left  damp  after  treatment.  Pro- 
tect the  bedding  underneath  the  patient  by  oil  cloth,  sheets,  and 
towels  as  necessary.  After  applying  a  fomentation,  cover  it 
with  a  dry  fomentation  cloth  or  a  newspaper  in  order  to  protect 
the  bedding  over  the  patient. 

(c)  The  Fomentation.  Prepare  a  set  of  four  or  six  fomenta- 
tion cloths,  thirty  to  thirty-six  inches  square.  Four  of  these 
may  be  cut  from  a  single  blanket.  The  material  should  be  half 
wool.  Three  cloths  are  necessary  for  one  fomentation  where 
they  are  to  be  very  hot — one  for  the  dry  covering  and  two  to  be 
wrung  from  boiling  water  for  the  inside  wet  part.  Where  less 
heat  is  required  one  inside  cloth  may  be  sufficient.  Two  such 
fomentation  sets  are  necessary  if  the  best  results  are  obtained. 

Spread  out  on  the  table  the  cloth  for  the  dry  covering.  Fold 
together  in  three  thicknesses  so  as  to  make  a  long  narrow  piece, 
the  cloth  or  cloths  to  be  used  inside;  and  holding  the  strip  by 
one  end,  immerse  in  the  boiling  water.  When  thoroughly  sat- 
urated with  the  boiling  water,  pass  it  quickly  through  the 
wringer  and  after  further  folding  or  readjusting  to  the  proper 

26 


402  TECHNIQUE 

shape  and  size  for  the  part  to  be  treated,  fold  it  quickly  inside 
the  dry  fomentation  cloth.  It  is  now  ready  for  use.  By  again 
doubling-  together  the  surface  of  the  fomentation  to  be  applied 
to  the  patient,  it  can  be  carried  with  less  loss  of  heat.  The 
fomentation  should  be  large  enough  to  cover  a  much  larger  area 
than  the  part  affected. 

Where  it  is  necessary  to  wring  the  fomentation  by  hand,  par- 
tially twist  the  long  folded  piece  while  it  is  held  doubled  to- 
gether with  one  hand  holding  each  end.  Both  ends  are  now 
grasped  in  one  hand  and  the  fomentation  dipped  into  the  boiling 
water.  When  it  is  ready  to  wring,  twist  tightly,  handling  the 
fomentation  cloth  by  the  dry  ends.  Next  pull  the  ends  apart. 
The  water  is  thus  squeezed  out.  (.Plate  XXII.}  The  twisting 
and  pulling  may  be  repeated  as  necessary  for  thorough  wringing 
of  the  cloth.  By  releasing  one  end  while  holding  up  the  cloth 
by  the  other,  it  may  be  quickly  untwisted  and  at  once  wrapped 
in  the  dry  covering. 

Where  it  is  necessary  to  give  the  treatment  in  the  patient's 
room,  a  set  of  three  fomentations  may  be  packed  in  a  papier 
mache  pail  in  such  a  way  as  to  preserve  their  heat  for  a  half 
hour  or  even  longer.  First,  line  the  pail  with  large,  dry  fomenta- 
tion cloths.  Prepare  each  fomentation  as  usual  and  pack  in 
tightly  or  better  still,  wring  by  hand  the  inside  cloths,  leaving- 
them  twisted  as  tightly  as  possible  and  pack  closely  in  the  lined 
bucket.  A  hot-water  bottle  may  be  placed  in  the  bottom  of  the 
pail  if  thought  necessary  and  another  over  the  wet  cloths.  The 
necessary  number  of  dry  fomentation  cloths  may  be  packed  into 
the  top  of  the  pail  and  the  fomentations  made  up  in  the  room  as 
needed. 

(d)  Procedure.  The  fomentation  should  lie  closely  in  contact 
with  the  skin,  and  be  renewed  in  three  or  four  minutes;  or  in 
case  of  pain,  as  soon  as  it  becomes  comfortable.  If  unbearably 
hot,  rub  the  part  with  the  hand  under  the  fomentation  or  re- 
move the  moisture  by  firm  rubbing  once  or  twice  with  a  Turk- 
ish towel  wrapped  about  the  hand.  The  fomentations  may  be 
applied  over  a  towel  in  order  to  temper  the  heat.  Always  be 
careful  to  protect  from  chilling  the  area  being  treated,  by  keep- 
ing it  covered  with  the  fomentation  cloth  or  a  towel. 


LOCAL  APPLICATIONS  OF  HEAT  403 

To  renew  the  fomentation,  prepare  another  similar  one  and 
apply  immediately  after  removing-  the  moisture  occasioned  by 
the  first.  Never  apply  another  fomentation  until  this  is  done, 
as  the  water  on  the  skin  makes  it  more  difficult  to  endure  the 
heat  of  the  newly  prepared  fomentation.  The  second  fomenta- 
tation  should  be  ready  to  apply  before  the  first  is  removed.  The 
removal  of  the  inside  cloth  from  the  outer  for  purposes  of  re- 
newal does  not  give  the  best  results,  although  careful  attention 
to  details  may  still  make  the  treatment  very  effective. 

Unless  otherwise  indicated  or  ordered,  three  successive  appli- 
cations are  made.  In  all  cases,  however,  they  should  be  con- 
tinued until  the  desired  effect  is  obtained.  After  the  last  one, 
the  part  should  be  immediately  cooled  by  a  wet  hand  rub,  cold 
compress,  or  rub  with  the  cold  wet  towel.  Dry  thoroughly  and 
cover  at  once  to  prevent  chilling.  In  some  cases  of  pain,  the 
part  should  be  dried  without  the  cold  application.  All  changes 
should  be  made  quickly,  and  the  part  treated  should  never  be 
left  uncovered. 

(e)  Precautions.  In  cases  of -unconsciousness,  paralyzed  sen- 
sation, diabetes,  dropsy,  under  anesthesia,  or  after  operations, 
great  care  must  be  taken  to  avoid  burning.  The  degree  of 
each  application  should  be  tested  by  the  back  of  the  hand  or  the 
face  before  being  applied  to  the  patient.  In  giving  fomenta- 
tions to  the  face  or  other  sensitive  part,  gauze  should  be  placed 
next  to  the  skin. 

In  case  of  general  perspiration,  a  general  cold  friction,  wet 
hand  rub,  wet  towel  rub,  or  alcohol  rub,  should  be  given. 

Sensitive  surfaces,  especially  bony  prominences  such  as  the 
ilia,  costal  arches,  clavicles  or  scapula,  may  need  to  be  protected 
by  extra  coverings  of  flannel  or  Turkish  towel. 

Where  the  patient  is  liable  to  cerebral  congestion,  and  always 
in  case  of  fever,  apply  cold  compresses  to  the  head  and  also  to 
the  neck  if  needed.  The  same  should  be  done  where  two  or 
more  applications  of  heat  are  made  at  the  same  time  or  general 
perspiration  induced.  In  case  of  heart  disease,  usually  in  fever, 
and  with  rapid  pulse  from  any  cause,  an  ice  bag  should  be 
placed  over  the  heart. 

In  order  to  relieve  pain,  the  fomentation  must  be  very  hot, 


404  TECHNIQUE 

as  hot  as  can  be  borne,  and  renewed  as  soon  as  it  becomes 
comfortable.  In  some  cases  of  pain  the  cold  application  at  the 
close  should  be  omitted,  the  part  being  dried  and  immediately 
covered  with  flannel  or  other  dry  covering-. 

For  sanitary  reasons  it  is  desirable  that  each  patient  furnish 
his  own  fomentation  cloths.  However,  persons  with  communi- 
cable diseases  should  not  be  admitted  to  a  general  treatment 
room. 

(f)  Effects.  The  fomentation  is  used  to  relieve  pain,  produce 
derivation,  as  a  preparation  for  cold  treatment,  and  for  stimu- 
lating or  sedative  effects,  according  to  the  temperature  and 
mode  of  application.  Its  first  effect  is  that  of  a  vital  stimulant; 
unless  followed  by  a  cold  application,  the  reaction  is  atonic.  A 
brief  application  is  stimulating;  prolonged  applications  sedative 
or  depressing.  For  sedative  effects  the  heat  should  be  moder- 
ate and  the  application  more  prolonged  before  renewal.  These 
points  should  be  observed  in  applying  fomentations  to  the  spine 
for  insomnia. 

Hot  Gauze  Compress — H.  Comp. 

This  is  used  when  it  is  desired  to  apply  moist  heat  to  such 
sensitive  parts  as  the  eye,  a  wound  or  infected  part  where  the 
cloth  must  be  disinfected  or  discarded  after  being  used. 

Several  thicknesses  of  gauze,  cheesecloth  or  ordinary  cotton 
cloth  of  appropriate  size  and  shape,  are  wrung  from  boiling 
water  and  applied  in  the  same  way  as  a  fomentation.  Because 
the  compress  is  usually  small  and  unprotected,  it  cools  quickly, 
and  for  this  reason  must  be  more  frequently  renewed,  nor  does 
cotton  hold  heat  as  long  as  wool.  From  ten  to  fifteen  minutes 
will  usually  suffice  to  obtain  the  desired  result.  The  treatment 
should  be  concluded  in  a  manner  similar  to  the  fomentation. 

Stupes 

A  stupe  consists  in  the  application  of  a  medicament  by  means 
of  a  fomentation.  When  gauze  compresses  are  used,  the  disin- 
fectant or  medicament  may  be  put  into  the  hot  water  from  which 
the  compress  is  wrung.  In  case  of  a  large  fomentation  with 
flannel  cloths,  the  medicament  may  be  applied  by  compresses 


PLATE  XXIV.     Steam  boxes  for  heating  fomentations  and  packs— closed. 


PLATE  XXV.     Steam  boxes  for  heating  fomentations  and  packs— open  and  in  vise. 


LOCAL  APPLICATIONS  OF  HEAT  405 

placed  under  the  fomentation.  Turpentine,  mustard,  menthol, 
etc.,  may  be  used  in  this  way.  However,  the  desired  hyper- 
emia  and  depletion  can  usually  be  obtained  in  a  more  cleanly 
manner  by  a  plain  fomentation,  and  without  the  danger  of  a 
blister. 

To  prepare  a  mustard  fomentation,  make  a  thin  paste  of  mus- 
tard and  spread  on  a  piece  of  gauze  or  muslin  of  the  desired 
shape  and  size,  apply  this  to  the  surface  to  be  treated  and  cover 
with  the  fomentation.  To  prepare  a  turpentine  stupe,  sprinkle 
on  ths  wet  gauze  half  a  teaspoonful  of  oil  of  turpentine,  apply 
and  cover  with  a  fomentation.  If  the  stupe  is  to  be  left  on 
some  time,  it  will  be  better  to  wring  the  gauze  from  a  dilute 
solution  of  turpentine  (10  to  20  per  cent). 

Revulsive  Compress — Rev.  Comp. 

This  is  given  in  the  same  manner  as  the  fomentation,  with 
the  addition  of  a  cold  compress  after  each  application  of  heat. 
A  hand  towel  is  wrung  from  cold  water  or  ice  water,  according 
to  the  ability  of  the  patient  to  react.  This  is  spread  out  over 
the  surface  immediately  on  the  removal  of  the  fomentation, 
allowed  to  remain  a  few  seconds,  and  then  turned  over  and 
allowed  to  remain  about  thirty  seconds.  The  skin  is  now  dried 
and  the  next  fomentation  applied.  Three  changes  of  hot  and 
three  of  cold  are  usually  employed. 

The  revulsive  compress  is  a  mild  stimulant  and  tonic  measure,, 
it  also  produces  mild  fluxion  in  the  part  treated. 

Alternate  Hot  and  Cold  to  Spine — H.  &  C.  Sp. 

Fomentations  are  given  in  the  same  manner  as  for  the  revul- 
sive compress.  After  each  a  smooth  piece  of  ice  is  quickly 
rubbed  back  and  forth  over  the  part,  making  from  three  to  five 
or  more  to-and-fro  movements.  The  part  is  then  dried  and 
another  fomentation  applied.  In  making  these  hot  and  cold 
applications,  the  next  fomentation  should  be  ready  before  the 
ice  is  applied. 

Alternate  hot  and  cold  applications  may  be  made  to  other 
parts  in  the  same  manner. 

Alternate  hot  and  cold  to  the  spine  is  a  vigorous  stimulant 
and  tonic  measure  and  is  useful  in  a  great  variety  of  conditions. 


406  TECHNIQUE 

Alternate  Hot  and  Cold  to  Head— H.  &  C.  Hd. 

(a)  Articles  Necessary.  Two  compresses  of  three  to  five 
thicknesses  of  gauze  or  cheesecloth  about  twelve  inches  square, 
two  ice  bags  rilled  with  finely  chopped  ice  and  covered  with 
cheesecloth,  a  spine  bag  partly  filled  with  hot  water  and  cov- 
ered with  a  fomentation  cloth  or  towel,  a  bowl  of  ice  water  and 
a  pail  of  boiling  water. 

(£)  Procedure.  Place  the  spine  bag'  crosswise  of  the  cervical 
spine,  bringing  it  well  up  under  back  of  head  and  neck.  Lightly 
wring  cheesecloth  from  ice  water  and  apply  to  face,  covering- 
top  of  head  and  ears.  Press  down  firmly  over  forehead  and 
temporal  arteries;  renew  every  minute. 

After  three  minutes  replace  spine  bag  by  two  cloth-covered 
ice  bags,  and  the  cold  compress  to  face  by  another  wrung  quite 
dry  from  hot  water;  the  latter  should  be  renewed  every  minute. 
In  another  three  minutes  replace  the  first  applications  of  spine 
bag  to  the  back  of  the  neck  and  cold  compress  to  the  face. 
Continue  these  alternations  for  three  complete  sets  of  hot  and 
cold.  Cool  all  the  parts  by  wiping  off  with  a  cold  compress 
and  dry  thoroughly,  especially  the  hair. 

(c)  Effect.  These  alternating  hot  and  cold  applications 
stimulate  the  cerebral  circulation  and  the  treatment  is,  there- 
fore, indicated  in  headache  due  to  anemia  of  the  brain,  also  in 
passive  congestion  and  in  a  cold  in  the  head.  Any  alternating 
hot  and  cold  application  produces  fluxion. 

Simultaneous  Hot  and  Cold  to  Head — Simul.  H.  &  C.  Hd. 

Place  an  ice  bag  to  the  base  of  the  brain  and  another  ice  bag, 
or  better,  ice  cap,  to  the  vertex  after  moistening  the  hair  so  that 
the  cold  will  penetrate.  Also  place  ice  bags  or  ice  compresses 
over  the  carotids.  Now  apply  a  fomentation  to  the  face,  cover- 
ing the  ears  and  forehead.  Gauze  or  cheesecloth  should  be 
used  under  the  fomentation  when  applied  to  the  face.  The 
.  nose  should  not  be  covered  by  the  fomentation  as  it  is  uncom- 
fortable when  so  done,  and  it  is  better  for  the  patient  to  breathe 
cooler  air. 

This  treatment  is  very  effective  in  reducing  cerebral  conges- 
tion and  relieving  congestive  headache.  It  is  well  to  conclude 


LOCAL  APPLICATIONS  OF  HEAT  407 

the  treatment  by  an  alternate  hot  and  cold  percussion  douche 
to  the  feet,  cold  cervical  and  cephalic  compresses  being  kept  on 
while  giving  the  douche. 

Simultaneous  applications  of  heat  and  cold  so  given  that  the 
cold  application  is  placed  over  a  reflex  area  of,  or  the  large 
artery  supplying,  the  deep  part,  produce  depletion. 

Hot-Water  Bottles 

These  should  be  partly  filled  with  hot  water  (never  boiling 
water)  and  wrapped  in  cloth,  preferably  flannel  or  a  Turkish 
towel.  Great  care  should  be  taken  in  applying  them  to  patients 
with  paralysis  and  during  and  after  operations  that  burns  do 
not  result.  The  safety  of  the  hot-water  bottle  may  be  tested  by 
holding  it  against  the  cheek.  When  not  in  use,  the  bottle 
should  be  hung  bottom  end  up  with  the  stopper  out.  It  should 
never  be  left  doubled  sharply  upon  itself  as  it  is  likely  to  crack 
at  the  fold.  The  hot -water  bottle  is  made  in  two-  and  three- 
quart  sizes.  The  spinal  hot-water  bottle  is  useful  in  giving  hot 
packs,  also  for  the  local  application  of  heat  to  the  spine  or  legs. 
The  metal  hot-water  bottle  is  very  durable.  It  is  serviceable  as 
a  bed  warmer  and  for  the  feet.  It  must  be  well  covered  and 
great  care  exercised  in  its  use  that  burns  are  not  produced  by 
leaving  some  part  of  the  metal  exposed.  These  bottles  are 
shown  in  Plate  XX  VI. 

Fomentations  and  hot  packs  may  be  reenforced  or  prolonged 
by  the  use  of  hot- water  bottles,  or  the  bag  may  be  wrapped  in 
a  moist  cloth  covered  over  by  a  dry  one,  to  give  the  effects  of 
a  mild  fomentation. 

Winternitz  Coil 

This  consists  of  a  coil  of  rubber  tubing  about  ten  or  eleven 
inches  in  diameter,  through  which  a  stream  of  hot  water  is 
caused  to  flow.  (Fig.  60.)  A  dry  blanket  is  placed  on  the 
treatment  table,  and  over  this  is  placed  a  doubled  sheet,  wrung 
from  cold  water  or  ice  water,  so  that  it  may  be  wrapped  about 
the  trunk.  The  patient  lies  down  on  the  wet  sheet  and  one  end 
is  wrapped  tightly  about  the  chest  and  abdomen.  The  coil  is 
now  placed  on  the  abdomen  over  the  wet  sheet,  and  the  other 
end  of  the  sheet  wrapped  around  the  trunk  over  the  coil.  The 


408 


TECHNIQUE 


dry  blanket  is  folded  over  and  about  the  patient.  A  small 
stream  of  hot  water  at  135°  flows  slowly  through  the  coil  from 
the  center  outwards.  The  treatment  is  continued  from  thirty 
to  forty  minutes,  or  even  three  hours  in  cases  of  very  slow  and 
defective  digestion.  It  is  concluded  by  a  cold  mitten  friction. 
A  hot- water  bottle  may  be  used  in  place  of  the  coil.  (See  hot 
and  heating"  trunk  pack.) 

The  coil  may  be  used  for  cold  water  in  the  same  manner  as 
the  Leiter  coil.  In  fact  the  cold  coil  is  much  more  frequently 
used  and  for  a  greater  number  of  purposes  than  the  hot  coil. 


Fig.  59.    Three  sizes  of  radiant  heat. 

Radiant  Heat— Rad.  Heat. 

The  radiant  heat  is  a  local  application  of  heat  by  means  of 
electric  lights  arranged  in  a  reflecting  metal  case.  {Fig.  59.) 
From  one  to  twelve  or  more  such  lights  may  be  arranged  in  a 
single  case,  and  the  case  so  constructed  as  to  fit  to  any  part  of 
the  body.  An  instrument  with  one  light  is  perhaps  the  most 
useful.  An  oblong-  case  containing-  three  lights  is  a  convenient 
means  of  applying  heat  to  the  spine.  A  case  in  the  shape  of  a 
half  cylinder  and  containing  six  or  more  lights  may  be  made 
for  the  feet  and  legs. 

In  applying  the  radiant  heat,  the  body  should  be  protected 
from  the  edge  of  the  case  by  towels  or  fomentation  cloths.  The 


LOCAL  APPLICATIONS  OF  COLD  409 

amount  of  heat  may  be  regulated  by  the  number  of  lights  or  the 
distance  from  the  skin.  Leave  in  place  for  ten  to  twenty 
minutes,  or  until  the  desired  results  are  obtained.  Cover  the 
part  well  after  drying-  perspiration,  or  use  a  cold  wet  towel. 
The  local  electric  light  is  a  convenient  means  of  applying  heat 
to  the  feet,  knees,  and  other  joints.  It  may  be  used  over  band- 
ages and  surgical  dressings  where  it  is  not  desirable  to  remove 
them. 

LOCAL  APPLICATIONS  OF  COLD 
Cold  Compress — C.  Comp. 

A  cold  compress  is  a  local  application  of  cold  by  means  of  a 
cloth  wrung  from  cold  water.  Hand  towels,  ordinary  cotton 
cloths,  or  better  still,  cheesecloth  may  be  used.  These  should 
be  folded  to  the  desired  size,  and  wrung  from  cold  water  or  ice 
water.  The  wringing  should  be  just  sufficient  to  prevent  drip- 
ping. They  will  be  colder  if  taken  immediately  from  a  block  of 
ice.  As  a  continuous  cold  application,  the  compress  must  be 
very  frequently  renewed,  always  before  it  is  warmed  to  any 
great  extent.  The  thicker  the  compress,  the  less  frequently 
will  it  require  renewal.  A  set  of  two  compresses  should  be 
used  and  renewed  at  intervals  of  from  one  to  five  minutes 
depending  on  the  thickness  of  the  "compress  and  the  result  to  be 
obtained.  Cold  compresses  may  be  applied  to  the  head,  neck, 
over  the  heart  or  lungs,  to  the  abdomen,  spine,  etc.  When 
applied  to  the  head  they  should  be  pressed  firmly  down  on  the 
surface  being  treated,  especially  over  the  forehead  and  the  tem- 
poral arteries.  The  pillow  should  be  protected  by  rubber  cloth 
covered  by  a  towel.  When  applied  to  the  abdomen  in  typhoid 
fever,  the  bedding  and  patient's  garments  should  be  protected 
by  Turkish  towels.  Unless  very  thick  and  always  when  left 
longer  than  three  to  five  minutes,  the  nature  of  the  application 
changes  and  it  becomes  a  heating  compress. 

When  applied  over  a  large  artery  it  decreases  the  amount  of 
blood  in  the  part  beyond  the  application.  Such  an  application 
is  called  a  proximal  compress.  Examples  of  this  are  found  in 
such  applications  as  a  cold  compress  to  the  neck,  over  the 
femoral  artery,  at  the  bend  of  the  elbow,  etc.  Ice  bags  are 
also  used  for  the  same  purpose. 


410  TECHNIQUE 

Ice  Pack— Ice  Pk. 

An  ice  pack  is  used  where  a  large  continuous  and  very  cold 
application  is  desired.  Spread  cracked  ice  over  a  thick  Turkish 
towel ,  folding-  one  end  and  the  edges  over  this  so  as  to  retain 
the  ice.  Apply  next  to  the  skin  or  over  a  single  layer  of 
flannel.  This  may  be  used  over  the  heart,  also  over  a  consoli- 
dated lung  area  in  pneumonia.  In  the  latter  case  it  should 
never  be  applied  until  after  the  hot  packs  used  in  this  disease 
have  warmed  the  body  sufficiently  to  prevent  chilling.  It 
should  occasionly  be  interrupted  by  applying  a  fomentation. 
This  helps  to  preserve  the  desired  reflex  effect. 

Snow  may  be  used  in  place  of  the  pounded  ice.  In  applying 
an  ice  pack  to  a  joint,  first  wrap  the  part  in  flannel  so  as  to 
prevent  actual  freezing,  then  pack  the  snow  or  pounded  ice 
closely  against  the  flannel  forming  a  layer  about  one  inch  thick, 
retaining  it  in  place  by  a  larger  flannel  cloth  wrapped  about  all 
and  pinned  together  (Plate  XIII.}.  Several  gum  rubber  ice 
bags  filled  with  snow  or  pounded  ice  are  better  for  pack  pur- 
poses, as  there  is  no  danger  of  wetting  the  bed  linen. 

Ice  packs  should  be  interrupted  often  enough  to  prevent 
freezing,  and  the  part  either  rubbed  with  snow  or  a  fomenta- 
tion applied  to  renew  the  local  reaction. 

Ice  Cravat 

The  ice  cravat  or  collar  is  made  in  the  same  way  as  the  ice 
pack,  the  towel  being  filled  with  ice  and  folded  so  as  to  be 
about  three  inches  wide  and  encircle  the  neck.  If  the  towel  is 
wrung  from  ice  water,  it  must  be  more  frequently  renewed 
than  when  cracked  ice  is  used. 

An  ice  cravat  may  also  be  made  by  using  two  narrow  spinal 
ice  bags  (Plate  XXVII,  fig.  J.).  These  should  be  filled  with 
pounded  ice  and  wrapped  in  linen  or  cotton  cloth. 

The  effect  is  that  of  a  proximal  application.  The  carotid 
arteries  and  their  distal  branches  are  contracted,  also  the  verte- 
bral arteries.  Thus  the  blood  supply  to  the  brain  and  head 
generally  is  very  much  lessened.  The  ice  collar  is  frequently 
used  in  fever,  in  congestive  headache,  in  acute  epidemic  men- 


LOCAL  APPLICATIONS  OF  COLD 


411 


ingitis,  etc.  It  should  also  be  used  in  sunstroke  and  whenever 
prolonged  sweating-  treatments  are  given,  as  in  eclafnpsia  and 
uremia. 

Ice  Bag  and  Ice  Cap — Ice  Bg. 

Ice  bags  are  made  in  various  shapes  and  sizes  (.Plate  XXVII.} . 
The  best  ice  bags  are  made  of  pure  gum  rubber  and  are  usually 
elliptical  in  shape.  They  may  be  obtained  in  almost  any  size 
desired.  The  spinal  ice  bag  is  about  three  inches  wide  by 
seven  to  nine  or  ten  long. 

Ice  caps  are  usually  round  or  elliptical  and  provided  with  a 
screw  cap;  some  are  also  made  with  loops  or  eyelets  for  holding 
them  in  place.  Cloth-covered 
ice  bags  offer  no  advantage; 
they  usually  leak  after  being- 
used  a  few  times,  and  are  also 
unsanitary.  Japanese  paper  ice 
bags,  because  of  their  cheap- 
ness, may  be  thrown  away  after 
being"  used  in  infectious  cases. 
The  ice  bag  or  cap  should  be 
filled  with  finely  cracked  or 
pounded  ice,  never  with  large 
chunks.  In  closing  the  ice  bag 

the  neck  should  be  doubled  down,  then  folded  several  times 
across  this  and  tied  with  tape  about  one-fourth  inch  wide. 
Thread  or  fine  twine  should  not  be  used  as  it  cuts  the  rubber. 
When  applying-  the  bag,  wrap  it  in  a  towel  or  one  thickness  of 
flannel.  The  skin  should  not  be  severely  chilled.  The  bag 
should  be  removed  often  enough  to  prevent  this,  the  part 
rubbed  briskly  with  the  hand  until  warmed  or  a  fomentation 
applied  for  a  short  time. 

Cold  Water  Coil— C.  Coil. 

The  rubber  coil  (Winternitz  coil)  is  the  most  convenient 
means  of  applying  a  local  application  of  cold.  Matted  coils  ten 
or  eleven  inches  in  diameter  may  be  purchased  or  a  coil  may  be 
made  of  ordinary  rubber  tubing  and  held  tog-ether  by  adhesive 
tapes  (Fig.  60.}.  The  inflow  should  enter  at  the  center  of 


Fig.  60.    Winternitz  coil. 


412  TECHNIQUE 

the  coil.  The  rate  of  flow  may  be  very  conveniently  controlled 
by  tying  a  knot  in  the  outflow  tube  just  above  where  it  dips  into 
the  receiving:  pail.  This  knot  may  be  loose  or  tight  as  desired 
for  rapid  or  slow  flowing  of  the  cold  water  through  the  coil. 
The  reservoir  should  be  about  two  feet  above  the  level  of  the 
coil  and  may  be  a  large  can  with  an  outlet  at  the  bottom,  or  an 
ordinary  pail  may  be  used  and  the  outflow  secured  by  siphon- 
age. 

The  coil  should  always  be  applied  over  a  cold  compress  and 
covered  with  a  dry  flannel  cloth  or  fomentation  cloth.  In 
applying  it  to  the  head,  the  coil  may  be  made  in  the  shape  of  a 
cap  {Plate  F///.)  and  held  in  place  by  light  bandages  or 
folded  towels.  Always  wet  the  hair  before  placing  the  coil. 

The  Leiter  coil  is  not  used  as  much  as  the  rubber  coil.  It  is 
a  small  flat  coil  of  flexible  metal  tubing  through  which  a  stream 
of  cold  water  or  ice  water  passes.  It  may  be  moulded  to  fit 
any  part,  and  is  often  used  over  the  mastoid. 

HEATING  COMPRESSES 

A  heating  compress  is  a  cold  compress  so  covered  that  warm- 
ing up  soon  occurs.  The  effect  is,  therefore,  that  of  a  mild 
application  of  moist  heat. 

A  heating  pack  or  compress  consists  of  an  application  of  heat 
to  the  body  by  means  of  three  or  four  thicknesses  of  gauze  or 
one  of  linen  or  cotton  cloth  wrung  from  cold  water  and  so  per- 
fectly covered  with  dry  flannel  or  mackintosh  and  flannel  as  to 
prevent  the  circulation  of  air  and  cause  an  accumulation  of 
body  heat.  In  case  warming  does  not  occur  .promptly,  it  should 
be  aided  by  hot-water  bottles  or  the  radiant  heat.  It  is  usually 
left  in  place  for  several  hours  between  other  treatments,  or  over 
night.  If  left  on  over  night  it  should  be  dry  by  morning  unless 
an  impervious  covering  such  as  a  mackintosh  or  oiled  silk  is 
used.  On  removal  of  the  compress  the  part  should  be  rubbed 
with  cold  water. 

According  to  the  extent  and  location  of  the  surface  involved, 
the  nature  and  thickness  of  the  coverings,  the  temperature  and 
amount  of  water  left  in  the  wet  cloth,  and  the  duration  of  the 
application,  it  may  have  the  following  effects,  viz.,  tonic,  seda- 
tive, derivative,  or  sweating. 


PLATE  XXVIII.     1.  The  square  chest  pack.     2.  The  roller  chest  pack. 
3.  The  moist  abdominal  bandage. 


HEATING  COMPRESSES  413 

If  the  pack  dries  out  before  being-  removed,  it  will  have  a  mild 
derivative  and  a  mild  sedative  or  tonic  effect  according-  to  the 
part  to  which  it  is  applied  and  the  condition  in  which  it  is  used. 
If  the  covering's  prevent  drying,  the  result  will  be  that  of  a 
strong-er  derivative  because  of  the  local  sweating".  It  also 
causes  relaxation  of  the  muscles  and  vaso-dilatation  of  the  ves- 
sels in  immediate  or  reflex  relation  with  the  surface  treated. 

Moist  Chest  Pack— Ch.  Pk. 

Any  kind  of  a  jacket  which  combines  the  above  requisites  for 
a  heating  compress  with  ease  and  neatness  of  application  and 
accuracy  of  fit,  will  answer  the  purpose  of  a  chest  pack.  The 
roller,  square,  and  fitted  chest  packs  are  examples  of  these. 

1.  Roller  Chest  Pack.     The  inside  piece  consists  of  two  to 
four  thicknesses  of  gauze  eight  to  ten  inches  wide  and  about 
six  or  eig-ht  feet  in  length.     One  thickness  of  thin  linen  may  be 
used.     The  outside  piece  of  flannel  is  a  little  wider  than  the 
g-auze  and   somewhat  longer    (Plate  XXVIII,  middle  figure.}. 
The  gauze  or  linen  is  loosely  rolled  in  bandage  form  and  wrung 
nearly  dry  from  cold  water.     While  standing-  in  front  of  the 
patient,  the  end  is  applied  under  one  arm,  more  handily  the 
right,  then  carried  diagonally  across  the  front  of  the  chest  and 
over  the  left  shoulder,  then  obliquely  across  the  back,  under 
the  right  arm  and  directly  across  the  front  of  the  chest,  under 
the  left  arm,  across  the  back  and  over  the  right  shoulder  and 
fastened  under  the  transverse  front  piece.     The  bandage  must 
be  snugly  applied  at  all  places  but  not  so  tight  as  to  restrict 
the  movements  of  the  chest.     The  flannel  is  now  applied  in  the 
same  order,  care  being  taken  that  the  wet  piece  is  well  covered 
and  then  securely  fastened  with  safety  pins.     The  pack  should 
be  comfortable  and  feel  warm  in  a  very  short  time.     (Plates 
XXIX  and  XXX.) 

2.  Square  Chest  Pack.      Both  parts  of  the  pack  are  of  an 
oblong  form    (Plate  XXVIII,  upper  figiire.),   wide  enough  to 
reach  from  the  top  of  the  shoulder  to  the  lower  ribs,  and  long 
enough  to  give  a  double  thickness  in  front.     The  ends  of  the 
bandage  are    slit  into  two  strips  one-third  and  two-thirds  re- 
spectively of  the  total  width,  and  each  one-third  of  the  length. 


414  TECHNIQUE 

The  outer  flannel  part  should  be  about  two  inches  wider  and  of 
the  same  length  and  slit  in  the  same  fashion.  The  flannel  part 
should  be  spread  out  on  the  treatment  table  and  the  linen  over 
it  after  being  wrung  from  cold  water.  The  patient  now-  lies 
back  on  this.  The  narrow  strips  are  brought  up  over  the 
shoulder  and  across  the  chest.  (Plates  XXXI  and  XXXII.} 
The  top  of  the  wider  strips  should  fit  under  the  axilla  and  be 
brought  across  the  chest.  The  flannel  should  now  be  applied 
in  the  same  manner  and  at  all  loose  places  be  drawn  tight  or 
folded  in  and  the  whole  fastened  with  safety  pins. 

3.  Fitted  Chest  Pack.     From  flannel  cut  a  front  and  a  back 
piece  in  much  the  same  shape  as  for  a  vest  making1  the  neces- 
sary curved  cuts  about  the  arms  and  neck.     The  front  piece 
should  be  the  larger  so  as  to  come  back  under  the  arms  and  lap 
over  the  back  piece;  also  on  each  side  of  the  neck,  a  strip  four 
inches  wide  should  be  made  long1  enough  to  overlap  the  back 
piece. 

An  inside  piece  of  the  same  shape  should  be  cut  from  gauze 
or  thin  linen.  This  inside  piece  should  be  about  one  and  one- 
half  inches  narrower  at  all  edges  so  that  when  covered  by  the 
flannel  it  will  not  be  exposed  at  any  place,  but  be  covered  at 
least  one  inch  beyond  its  edge. 

After  applying  see  that  it  fits  snugly  and  is  well  pinned  with 
safety  pins  so  as  to  prevent  the  entrance  of  air  at  any  place 
along  the  edges. 

Various  other  forms  may  be  improvised  to  meet  the  needs  of 
the  home  not  provided  with  the  more  perfect  requisites.  To 
retain  the  moisture  and  so  give  greater  sweating  effects  the 
cloth  may  be  covered  with  mackintosh,  gossamer  cloth,  or  oiled 
silk  of  the  same  size  and  shape.  When  so  covered  it  is  spoken 
of  as  a  protected  chest  pack. 

4.  Partial  Chest  Pack.      It  is  often  desirable  to  apply  the 
moist  cloth  to  only  a  portion  of  the  chest.     The  gauze  or  linen 
may  be  cut  to  any  desired  shape  and  size   and  applied  to  the 
proper  area  under  the  square  or  roller  flannel  pack.     The  chest 
being  covered  principally  by" dry  flannel,  this  form  approaches 
in  effect  the  dry  pack. 


HEATING  COMPRESSES  415 

Dry  Chest  Pack— Dry  Ch.  Pk. 

With  the  dry  chest  pack  only  the  flannel  is  used  of  either  the 
roller,  square,  or  fitted  style.  It  should  usually  be  applied 
over  a  thin  undergarment.  The  dry  chest  pack  is  desirable  in 
thin  persons,  the  aged,  and  those  having  insufficient  body  heat 
to  warm  up  the  wet  pack.  It  is  often  difficult,  not  to  say 
impossible,  in  the  case  of  a  thin  person,  to  pin  the  wet  pack  so 
tightly  as  to  prevent  the  air  from  circulating  under  the  edges  of 
the  pack  and  yet  loose  enough  to  be  comfortable  and  not  restrict 
the  breathing.  In  many  cases  a  chamois  vest  may  be  worn 
over  a  thin  undergarment  to  produce  the  effects  of  a  dry  pack. 

Chest  packs  are  of  much  benefit  in  pleurisy,  colds,  influenza 
of  the  respiratory  type,  during  convalescence  from  pneumonia, 
in  asthma,  whooping  cough,  croup,  etc.  Under  the  pack,  the 
skin  should  be  warm  and  gently  perspiring.  The  choice  of  a 
dry  or  moist  pack  will  depend  upon  the  vitality  of  the  patient 
and  the  result  to  be  obtained. 

Moist  Abdominal  Bandage — M.  A.  B. 

The  umschlag  or  moist  abdominal  girdle  is  one  of  the  most 
useful  of  the  heating  compresses.  The  inside  part  of  the  girdle 
{Plate  XXVIII,  lower  figure.}  consists  of  one  thickness  of  linen 
or  three  or  four  of  gauze,  eight  or  nine  inches  wide  and  a  little 
more  than  one  and  one-half  times  the  circumference  of  the 
body.  The  outer  flannel  girdle  should  be  about  twelve  inches 
wide  and  of  the  same  length.  The  dry  flannel  is  placed  across 
the  table  and  the  gauze,  wrung  nearly  dry  from  cold  water, 
placed  over  it.  The  patient  now  lies  back  on  the  bandage  so 
that  the  lower  edge  will  be  below  the  iliac  crests.  Each 
end  of  the  wet  linen  or  gauze  is  pulled  tightly  across  the 
abdomen  and  tucked  under  the  opposite  side.  (Plate  XXXIII.} 
Both  ends  of  the  flannel  are  now  folded  tightly  over  these  and 
securely  fastened  with  safety  pins.  Darts  may  be  taken  on 
each  side  by  means  of  safety  pins  in  the  same  manner  as  in 
pinning  a  bandage  after  an  abdominal  operation.  The  flannel 
piece  should  project  one  and  one-half  or  two  inches  beyond  the 
wet  gauze  or  linen.  .  Where  it  is  difficult  for  the  patient  to 
warm  up  the  bandage,  it  may  be  moistened  only  over  the 
abdomen. 


416  TECHNIQUE 

The  moisture  may  be  retained  by  a  bandage  of  oiled  silk  or 
mackintosh  of  the  same  width  as  the  linen  and  applied  between 
it  and  the  flannel.  This  is  spoken  of  as  a  protected  girdle. 

The  sweating"  underneath  will  be  more  profuse  than  without 
the  impervious  covering.  Since  the  moisture  is  retained  it  will 
not  be  dry  by  morning.  The  protected  girdle  is  indicated  in 
hyperacidity  and  where  it  is  desirable  to  produce  considerable 
relaxation. 

The  ordinary  moist  abdominal  bandage  is  useful  in  nearly  all 
forms  of  atonic  indigestion,  in  neurasthenia,  anemia  of  the 
liver,  insomnia,  catarrhal  jaundice,  constipation,  etc.  In  these 
conditions  it  is  usually  warn  only  at  night. 

Heating  Throat  Compress 

Four  to  six  thicknesses  of  cheesecloth  or  two  or  three  of 
ordinary  cotton  cloth  about  three  inches  wide  and  long  enough 
to  encircle  the  neck  twice  are  used  inside.  The  outside  consists 
of  two  thicknesses  of  flannel  not  less  than  four  inches  wide. 
This  compress  being  small,  considerable  water  may  be  left  in 
it  and  still  be  found  dry  by  morning.  The  neck  should  be 
rubbed  with  cold  water  immediately  after  removing  the  com- 
press in  the  morning.  The  "cold  cloth  around  the  neck  "  is  a 
very  common  household  remedy  for  sore  throat,  hoarseness, 
tonsillitis,  etc.  It  is  indeed  a  very  efficient  measure;  its  useful- 
ness can  hardly  be  overestimated.  The  heating  throat  com- 
press is  indicated  in  pharyngitis,  acute  laryngitis,  tonsillitis, 
quinsy,  and  in  inflammation  of  the  Eustachian  tube.  It  is  also 
useful  in  clergyman's  sore  throat.  In  tonsillitis,  quinsy,  and 
inflammation  of  the  Eustachian  tube,  the  compress  should 
extend  upward  about  the  lower  part  of  the  ear  and  may  be  held 
in  place  by  a  bandage  over  the  top  of  the  head. 

Heating  Joint  Compress 

Heating  compresses  may  be  applied  to  the  foot,  ankle,  knee, 
hand,  wrist,  etc.  Rarely  more  than  two  thicknesses  of  gauze 
are  used.  It  is  often  necessary  to  use  cotton  for  a  covering  to 
obtain  close  application  to  the  skin  surface.  This  may  be  held 
in  place  by  a  three-inch  roller  bandage  or  a  broad  flannel  cloth. 


POULTICES  417 

A  dry  pack  may  be  made  of  cotton  or  soft  flannel  alone.'  In 
certain  cases  the  joints  may  be  rubbed  with  a  medicated  solu- 
tion before  being-  covered,  or  the  gauze  dipped  in  it.  Alkaline 
or  anodyne  solutions  are  very  frequently  used  in  this  way  in 
cases  of  rheumatism.  In  rheumatic  fever  the  joints  may  be 
rubbed  with  synthetic  oil  of  wintergreen  before  the  heating- 
compress  is  applied.  It  helps  to  relieve  the  pain  and  by  its 
action  as  a  counter-irritant,  the  heating-  and  circulatory  effects 
are  enhanced. 

Medicated  Compresses 

Besides  rubbing-  the  parts  with  medicaments  such  as  turpen- 
tine, camphorated  oil,  oil  of  wintergreen,  etc.,  before  applying 
the  heating  compress  or  pack,  the  gauze  may  be  wrung  from 
various  solutions  such  as  an  alcoholic  solution  of  menthol, 
mustard  water,  watery  solution  of  bicarbonate  of  soda,  saltpeter, 
etc.  When  counter-irritant  drugs  are  used  the  effect  of  the 
heating  compress  is  intensified.  It  is  usually  not  desirable  to 
produce  a  blister.  For  this  reason  the  use  of  coal  oil  and  tur- 
pentine should  be  discouraged.  Not  only  may  they  produce 
blisters,  but  being  inflammable,  they  are  also  dangerous. 
When  using  oil  of  wintergreen  it  is  best  to  dilute  it  with  two 
parts  of  oil  of  eucalyptus. 

POULTICES 

Poultices  are  very  popular  substitutes  for  the  heating  com- 
press and  have  a  similar  effect.  They  consist  of  a  mixture  of 
various  substances,  having  the  consistency  of  mush  and  must 
be  applied  hot  to  produce  the  desired  result.  Flaxseed,  onions, 
etc.,  are  commonly  used.  The  preparation  may  be  applied 
directly  to  the  skin  or  spread  on  a  cloth  and  bound  tightly  to 
the  part.  They  are  often  disagreeable,  not  to  say  uncleanly. 

Probably  the  most  useful  poultice  is  that  consisting  of  white 
clay  and  glycerine  sold  under  various  names.  It  is  applied  hot 
about  one-quarter  to  one-half  an  inch  thick  and  covered  with 
cotton  and  a  bandage.  The  results  are  partly  due  to  the  heat 
and  partly  to  the  water-absorbing  (hygroscopic)  properties  of 
the  glycerine. 

27 


418  TECHNIQUE 

The  charcoal  poultice  is  especially  valuable  in  foul,  sloughing 
ulcers  or  wounds.  In  may  be  prepared  of  charcoal  alone  or  by 
adding  equal  parts  of  flaxseed  meal  and  powdered  charcoal  to 
boiling:  water  until  the  resulting-  mixture  is  the  consistency  of 
mush.  This  is  evenly  spread  on  a  cloth  and  applied  to  the 
part,  or  directly  on  the  part  and  covered  with  a  muslin  cloth 
and  some  impervious  cloth  as  oiled  silk. 

TONIC  FRICTIONS 

A  tonic  friction  is  an  application  of  cold  water  so  combined 
with  friction  as  to  produce  decided  thermic  and  circulatory 
reaction.  The  effects  are  briefly  described  as  stimulant  and 
tonic.  These  have  been  discussed  in  detail  in  the  chapter  on 
stimulants  and  tonics,  q.  v. 

Given  in  the  order  of  their  severity,  the  tonic  frictions  are  as 
follows:  Wet  hand  rub,  cold  mitten  friction,  cold  towel  rub, 
wet  sheet  rub,  and  dripping-  sheet  rub.  To  these  may  be 
added  the  ice  rub  and  salt  glow.  While  the  latter  is  not  par- 
ticularly an  application  of  cold,  the  friction  gives  tonic  results 
similar  to  the  others,  and  the  procedure  is  not  far  different. 
The  ice  rub  may  be  used  for  stimulant  or  tonic  purposes,  but  it 
is  more  frequently  used  as  an  antipyretic. 

Cold  Mitten  Friction — C.  M.  F.  or  Cmf. 

(a)  Articles  Required.     A  bowl  or  pail  of  cold  water  at  50° 
or  60°  F.  or  ice  water,  a  sheet,  three  Turkish  towels,  two  fric- 
tion mitts   made  of  such  coarse  material ,  as  woolen  moreene 
(see  corner  figure  in   Plate  XXXV.),    and  compresses  for  the 
head  and  neck. 

(b)  Procedure.     The  patient  should  be  warmly  covered  and 
the  feet  warm;  if  not,  give  hot  foot  bath.     Bare  one  part  of  the 
body  at  a  time.     Do  not  expose  any  part  longer  than  necessary; 
dry  quickly  and  thoroughly  and  recover  at  once  with  warm  dry 
covering.     Before  beginning  the  regular  part  of  the  treatment, 
bathe  the  patient's  face  and  neck  with  cold  water  or  apply  cold 
compresses  to  the  head  and  neck.     This  is  especially  necessary 
in  treating  patients  with  valvular  heart  disease.     In  this  con- 
dition an  ice  bag  should  be  placed  over  the  heart  before  begin- 


PLATE  XXXIII.    The  moist  abdominal  bandage. 


PLATE  XXXIV.    The  cold  towel  rub— treating  the  back. 


TONIC  FRICTIONS  419 

ning  treatment.     In  other  conditions  it  is  not  usually  necessary. 

Beginning  with  the  right  arm,  place  one  towel  under  the  arm 
and  another  around  the  shoulder  to  protect  the  table  and  pa- 
tient. With  the  mitts  on  the  hands,  dip  them  into  cold  water 
and  shake  or  squeeze  out  the  excess  of  water.  While  the  pa- 
tient holds  the  arm  at  an  angle  of  45  degrees,  rub  the  arm  and 
hand  with  rapid  to-and-fro  friction  movements  until  it  is  in  a 
glow  {Plate  XXXV.}.  Quickly  remove  the  mitts,  dropping 
them  into  the  bowl  and  cover  the  entire  arm  with  one  of  the 
Turkish  towels,  having  the  patient  hold  the  upper  corners  by 
closing  the  hand  on  them.  It  is  better  to  steady  the  arm  by 
grasping  the  patient's  hand  covered  by  the  towel,  under  the 
operator's  right  arm.  Dry  by  friction  outside  the  towel  and 
then  rub  with  the  towel  until  the  arm  is  thoroughly  dry  and 
well  reddened.  Treat  the  left  arm  in  the  same  manner. 

Now  covering  the  rest  of  the  body,  bare  the  chest  and  abdo- 
men. Tuck  a  Turkish  towel  snugly  under  each  side  along  the 
trunk  and  over  the  arms.  Rub  the  chest  with  the  mitten  dipped 
in  cold  water  in  a  manner  similar  to  the  arms,  then  cover  the 
entire  chest  with  one  of  the  towels  and  have  the  patient  catch 
the  two  upper  corners  as  they  lie  next  to  the  shoulders.  Rub 
briskly  with  downward  strokes  over  the  towel.  Then  wrap- 
ping the  towel  neatly  about  the  right  hand,  again  rub  the  en- 
tire surface,  around  shoulders  and  down  the  sides,  so  as  to  dry 
all  parts  that  have  been  wet. 

Cover  chest  and  expose  the  right  leg  and  thigh.  Flex  the 
leg  and  place  a  Turkish  towel  under.  Place  another  towel 
around  the  upper  thigh  at  the  groin.  Begin  the  friction  with 
the  leg  and  foot;  dip  the  mitts  again  for  the  thigh.  Treat  in 
like  manner  the  left  leg  and  thigh. 

Have  patient  turn  over  and  lie  on  a  pillow  placed  under  the 
chest.  Treat  the  back  in  the  same  manner  as  the  front  of  the 
trunk.  To  dry,  cover  the  entire  back  with  a  Turkish  towel 
and  have  the  patient  hold  the  upper  end  the  same  as  for  the 
chest;  rub  with  downward  strokes  over  the  towel  and  then 
wrap  the  towel  about  the  hand  and  rub  the  surface  again  until 
thoroughly  dry.  Some  prefer  to  begin  the  treatment  with  the 
chest  in  cases  of  heart  disease. 


420  TECHNIQUE 

To  vary  the  severity  and  tonic  effects,  the  temperature  of 
the  water  may  be  changed ;  more  may  be  left  in  the  mitts,  or 
the  mitts  dipped  two  or  three  times  in  treating-  each  part,  or 
the  friction  given  more  vigorously. 

Wet  Hand  Rub— W.  H.  R.  or  Whr. 

The  same  order  and  general  procedure  is  followed  as  for  the 
cold  mitten  friction.  One  part  at  a  time  is  bared,  rubbed  with 
the  hand  dipped  in  cold  water,  followed  by  percussion,  then 
dried,  finishing  with  brisk  rubbing  with  the  dry  towel  and  the 
hands.  Dipping  from  two  to  four  or  more  times  increases  the 
tonic  effect. 

Cold  Towel  Rub— C.  T.  R.  or  Ctr. 

In  giving  the  cold  towel  rub,  a  plain  hand  towel  is  used  in- 
stead of  the  mitts  employed  for  the  cold  mitten  friction.  The 
same  order  is  followed  as  in  the  two  previous  treatments,  be- 
ginning with  the  arms,  then  the  chest  and  abdomen,  legs,  and 
last,  the  back  (Plate  XXXIV.}. 

The  arm  is  held  vertically  with  the  palm  toward  the  feet;  the 
towel  is  dipped  in  cold  water  and  wrung  lightly,  quickly  un- 
folded and  wrapped  lengthwise  around  the  arm,  turning  the 
upper  corners  into  the  palm  to  be  grasped  by  the  hand  of  the 
patient,  or  the  arm  may  be  held  nearly  horizontal  while  the 
attendant  wraps  the  towel  spirally  about  the  arm  by  a  quick 
circular  movement.  The  part  is  then  rubbed  with  to-and-fro 
movements  outside  of  the  towel.  Percussion  may  also  be  given 
to  insure  a  greater  reaction.  The  towel  is  now  removed  and 
the  arm  dried  as  after  the  cold  mitten  friction. 

When  the  chest  and  abdomen  are  treated,  the  wet  towel  is 
spread  out  over  the  entire  surface  and  the  patient  grasps  the 
upper  corners  next  the  shoulders  and  holds  tightly  while  the 
nurse  rubs  with  downward  strokes  outside  the  towel.  The 
other  parts  are  treated  in  a  similar  manner. 

It  should  be  remembered  that  the  cold  towel  rub  takes  more 
heat  from  the  body  than  the  cold  mitten  friction,  and  it  there- 
fore requires  greater  reactive  ability  on  the  part  of  the  patient. 
Because  it  does  abstract  considerable  heat  from  the  body,  it  is 


TONIC  FRICTIONS  ]&i 

often  used  in  fever  as  an  antipyretic  measure.  By  dipping-  the 
towel  twice  or  more  for  a  single  part,  its  antipyretic  effects  are 
increased. 

Wet  Sheet  Rub— W.  Sh.  R. 

(a)  Requisites.  Two  sheets,  two  towels,  a  tub  containing 
hot  water  for  the  feet,  a  pail  of  water  at  60°— 70°  F.  Other 
temperatures  may  be  used  when  indicated. 

(£)  Procedure.  The  patient  should  be  warm  to  begin  with. 
Apply  a  cold  compress  to  the  head.  The  patient  now  stands 
in  the  tub  of  hot  water.  A  sheet  is  wrung  from  cold  water  so 
that  it  will  not  drip.  Quickly  wrap  the  sheet  about  the  patient 
as  follows:  The  patient  holds  up  both  arms.  The  upper  left- 
hand  corner  of  the  sheet  is  placed  under  the  patient's  right 
arm;  the  patient  then  lowers  the  right  arm,  thus  holding  the 
corner  of  the  sheet  in  place.  Pass  the  sheet  quickly  across  the 
front  of  the  body  and  under  the  left  arm,  which  is  lowered. 
The  sheet  should  then  be  carried  across  the  back,  behind  and 
up  over  the  right  shoulder  (.Plate  XXXVI.},  then  across  the 
chest  and  around  the  neck  over  the  left  shoulder,  tucking  the 
corner  under  the  edge  of  the  sheet  behind.  Now  tuck  the 
sheet  between  the  patient's  legs;  it  is  thus  brought  into  close 
contact  with  every  portion  of  the  skin.  Rub  vigorously  and 
give  percussion  over  the  sheet,  covering  the  whole  surface  as 
quickly  as  possible  until  the  sheet  is  thoroughly  warmed  {Plate 
XXXVII.}.  The  patient  is  not  to  be  rubbed  with  the  sheet, 
but  over  the  sheet.  Two  attendants  are  necessary  to  give  the 
best  results.  Dry  with  a  sheet  and  towels. 

The  wet  sheet  rub  is  a  very  vigorous  tonic  measure.  It 
should  not  be  used  until  the  patient  is  able  to  react  to  the  cold 
towel  rub,  the  pail  pour,  and  the  cold  percussion  douche. 

Dripping  Sheet  Rub — Drip.  Sh.  R. 

For  the  dripping  sheet  rub,  prepare  three  pails  of  cold  water 
at  about  70°,  65°,  60°  F.  respectively.  Proceed  as  with  the 
wet  sheet  rub,  using  the  water  at  70°  from  which  to  wring  the 
sheet.  After  the  sheet  and  patient  are  warmed  by  rubbing  and 
percussion,  without  removing  the  sheet,  pour  over  the  shoulders 
the  second  pail  of  water,  again  rubbing  vigorously  until  warm. 
Use  the  third  pail  in  like  manner.  Dry  as  after  wet  sheet  rub. 


422  TECHNIQUE 

Ice  Rub 

The  order  of  parts  treated  and  the  procedure  in  an  ice  rub 
are  substantially  the  same  as  in  the  wet  hand  rub  and  cold 
mitten  friction.  In  giving  the  ice  rub,  however,  it  is  necessary 
to  more  thoroughly  protect  the  bed  or  treatment  table  by  cover- 
ing with  oil  cloth  and  towels.  Turkish  towels  should  be  tucked 
closely  about  each  part  so  as  to  absorb  the  water  as  it  runs  off 
the  skin.  The  cake  of  ice  to  be  used  may  be  held  in  the  hand, 
or  better  yet,  wrapped  in  one  or  two  thicknesses  of  gauze. 

The  ice  rub  is  not  much  used  for  general  tonic  purposes,  but 
more  frequently  as  an  antipyretic.  When  used  for  this  pur- 
pose, each  part  should  be  rubbed  for  some  time  and  then  dried 
without  friction  or  percussion  with  the  hands.  Its  prolonged 
application  to  the  spine  is  more  decidedly  antipyretic  than  the 
same  length  of  application  elsewhere.  When  given  in  typhoid 
fever,  the  abdomen  should  be  avoided.  Cold  compresses  should 
be  applied  to  the  head  and  neck  and  also  to  the  heart  if  nec- 
essary. 

Salt  Glow— Sgl. 

Prepare  about  two  pounds  of  coarse  salt  wet  with  warm 
water.  The  treatment  should  be  given  in  a  "wet  room  ".or 
in  a  bath  tub.  The  patient  stands  in  a  tub  of  hot  water.  While 
standing  at  the  side  of  the  patient,  begin  with  the  arm.  Wet 
the  entire  skin  surface  of  the  shoulder,  arm  and  hand  with  hot 
water  from  the  foot  tub.  This  is  done  by  dipping  the  water 
with  the  hands.  Next  apply  the  wet  salt,  spreading  it  evenly 
over  the  skin.  Now,  with  one  hand  on  each  side  of  the  arm, 
rub  vigorously  with  to-and-fro  movements  until  the  skin  is  in  a 
glow.  Stepping  behind  the  patient  to  the  opposite  side,  pro- 
ceed in  the  same  manner  with  the  other  arm. 

Retain  the  last  position  to  treat  the  front  and  back  of  the 
trunk.  With  one  hand  in  front  and  one  behind,  wet  the  skin 
surface  with  hot  water  from  the  foot  tub.  Now  spread  the  salt 
as  before  and  rub  the  entire  skin  surface  of  the  chest,  abdomen, 
shoulders,  back,  and  buttocks.  Stepping  behind  the  patient 
and  with  one  hand  under  each  arm,  continue  rubbing  with  the 
salt,  treating  the  sides  of  the  chest,  abdomen,  and  the  hips. 


<  $ 

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SPONGING  423 

Next  proceed  with  the  legs  in  like  manner.  For  each  limb 
have  the  patient  put  one  foot  on  a  low  stool  so  as  to  bring  the 
thigh  about  horizontal.  Wet  with  water  as  before  and  rub  the 
thigh,  leg  and  foot  with  the  wet  salt.  Finish  the  treatment  by 
thoroughly  washing  off  the  salt.  This  may  be  done  by  a  pail 
pour,  shower  or  general  spray.  Dry  with  sheets,  towels  and 
fanning  with  a  dry  sheet  as  from  any  general  wet  treatment. 

If  for  any  reason  the  patient  ought  not  to  stand  so  long,  he 
may  be  seated  on  a  low  stool  while  the  salt  glow  is  given. 
Proceed  as  follows:  The  patient  sits  on  a  stool  with  the  feet  in 
hot  water.  Beginning  with  the  feet  and  legs,  apply  the  water 
and  then  the  salt,  rubbing  briskly  with  short  strokes,  the 
hands  being  on  either  side  of  the  part  treated.  Next,  treat 
each  arm  separately;  then  the  chest,  abdomen  and  back  should 
be  rubbed  with  the  wet  salt,  the  attendant  standing  at  the  side 
of  the  patient  with  one  hand  rubbing  the  chest  and  the  other 
the  back.  The  patient  should  stand  while  the  buttocks  and 
thighs  are  treated.  Wash  off  the  salt  and  dry  as  directed  above. 

The  salt  glow  is  a  vigorous  circulatory  stimulant.  Since  no 
great  amount  of  cold  water  is  applied  to  the  body,  it  does  not 
require  as  great  reactive  ability  as  the  wet  sheet  rub  or  cold 
douche . 

SPONGING 

Sponging  consists  in  the  application  of  a  liquid  by  means  of 
a  sponge,  a  cloth  or  the  bare  hand,  in  which  the  chief  effect  is 
derived  from  the  liquid  applied.  The  term  ablution  is  also 
applied  to  sponging. 

Plain  Water  Sponging— Spg. 

1.  Hot  Sponge— H.  Spg.  Hot  sponging  has  a  sedative  effect 
because  of  the  slightly  atonic  reaction  which  ensues.  It  is  also 
used  to  reduce  fever  where  chilliness  exists.  When  prolonged 
to  forty  or  fifty  minutes  the  temperature  does  not  rise  as  rapidly 
after  the  treatment  as  it  does  following  a  cold  sponge. 

A  large,  soft  sea  sponge  may  be  used,  a  soft  cotton  cloth,  a 
wash  cloth  of  Turkish  toweling,  or  several  thicknesses  of  cheese 
cloth.  The  water  should  be  as  hot  as  can  be  borne.  Bare  one 


424  TECHNIQUE 

part  at  a  time  and  treat  in  the  following-  order:  The  arms, 
chest,  abdomen,  legs,  thighs  and  back.  The  cloth  or  sponge 
should  be  dipped  several  times  for  each  part.  Dry  thoroughly. 

2.  Tepid  Sponge — Tepid  Spg.     The  tepid  sponge  has  an  effect 
similar  to  that  of  the  neutral  bath,  i.  e.,  it  is  sedative.     It  may 
also  be  used  to  reduce  fever  but  is  not  as  effective  as  either  the 
hot  or  the  cold  sponge. 

3.  Cool  or  Cold  Sponge — C.  Spg.     Cold  sponging  is  used  in 
the  treatment  of  fever  where  the  skin  is  hot  and  there  is  no 
tendency  to  chilliness.     Each  part  should  be  gone  over  several 
times.     The  temperature  of  the  water  and  the  duration  of  the 
treatment  should  be  governed  by  the  intensity  of  effect  desired. 

Saline  Sponge — Sal.  Spg. 

About  four  ounces  of  common  salt  are  dissolved  in  a  basin  or 
bowl  of  tepid  water.  The  bare  hand  is  dipped  in  the  salt  water 
and  each  part  rubbed  lightly. 

The  saline  sponge  has  a  mild  tonic  effect.  Because  of  the 
salt,  it  stimulates  the  vaso-motors  to  a  greater  extent  than  plain 
water. 

Alkaline  Sponge — Alk.  Spg. 

Use  about  two  ounces  of  bicarbonate  of  soda  to  a  small  basin 
of  hot  or  cool  water  according  to  the  case.  Apply  with  the  bare 
hand,  a  soft  cloth  or  sponge.  The  alkaline  sponge  is  useful  in 
itching,  smarting  and  other  abnormal  sensations.  It  is  usually 
applied  only  to  the  part  affected. 

Vinegar  and  Salt  Rub  . 

The  vinegar  and  salt  rub  is  very  useful  in  checking  the  exces- 
sive perspiration  or  night  sweats  of  phthisis. 

Prepare  a  half  pint  of  equal  parts  of  vinegar  and  water  to 
which  add  one  or  two  tablespoonfuls  of  salt.  Apply  with  the 
bare  hand,  drying  lightly  afterward.  The  application  should  be 
thorough  to  the  parts  that  perspire  the  most;  other  parts  may 
be  gone  over  less  thoroughly. 

Alcohol  Rub— Ale.  R. 

The  alcohol  rub  is  frequently  used  following  a  sweating  treat- 
ment instead  of  the  cold  friction  or  spray.  Its  purpose  is,  of 


RUBS  AND  FRICTIONS  425 

course,  the  prevention  of  taking-  cold.  Use  one  part  of  alcohol 
to  one  part  of  water  (proof  spirit,  50  per  cent) .  Dip  the  hands 
in  the  alcohol  and  rub  each  part,  dipping-  the  second  time  if 
needed.  No  drying-  with  the  towel  is  necessary. 

Witchhazel  Rub— Wzr. 

The  witchhazel  rub  has  about  the  same  effect  as  the  alcohol 
rub.  It  is  sedative  and  a  mild  astringent.  The  same  procedure 
is  used  as  for  the  alcohol  rub. 

Menthol  Rub— Menth.  R. 

The  application  of  menthol  to  the  skin  gives  a  sensation  of 
cold.  The  effect  is  similar  to  that  of  the  alcohol  rub  or  cold 
sponging.  Use  one  ounce  of  menthol  liniment  (menthol  cryst. 
1  oz.,  alcohol  1  pint)  to  three  or  four  ounces  of  water. 

Soap  Wash 

The  soap  wash  is  used  for  cleansing  the  skin  in  the  case  of 
bed  patients.  Using-  a  bowl  of  water  at  102°  F.,  with  soap  and 
wash  cloth  go  over  each  part  separately.  With  another  bowl  of 
water  at  75° — 85°  F.  and  another  cloth,  remove  the  soapy 
water  and  dry  thoroughly  with  a  Turkish  towel.  Each  part  is 
g-one  over  with  the  soapy  water  followed  by  rinsing  with  plain 
cool  water  and  then  dried  before  the  next  part  is  treated. 

RUBS  AND  FRICTIONS 

These  terms  are  applied  to  procedures  in  which  the  chief  effect 
is  derived  from  friction  with  the  bare  hands. 

Centripetal  Friction — C.  F.  or  cf. 

The  centripetal  friction  consists  principally  of  friction  strokes 
from  the  periphery  toward  the  center.  It  is  designed  to  hasten 
the  circulation,  especially  in  the  superficial  veins. 

General  Order  of  Movements:— 

1.  Light  to-and-fro  friction,  once. 

2.  Apply  lubricant,  twice. 

3.  Centripetal  friction,  three  times. 

4.  Percussion,  twice. 

5.  Stroking  (centrifugal),  three  times. 


426  TECHNIQUE 

ARMS 

1.  Beginning-  at  fingertips,  give  light,  quick  to-and-fro  fric- 
tion to  the  shoulder,  being  sure  to  cover  thoroughly  the  whole 
surface.     Let  the  hands  glide  back  as  in  stroking  the  arm. 

2.  Apply  lubricant  with  long  strokes  from  fingertips  to  shoul- 
der, returning  with  four  rotary  sweeps.     Give  twice. 

3.  Friction. 
Hand. 

(a)  Heavy    centripetal   stroking  to   back    of   hand,    three 
times. 

(b)  Palm  of  hand  same  as   back  of  hand,   beginning  at 
fingertips.     Finish  with  double  rotary  movement  in  palm.     Give 
three  times. 

Arm  and  Forearm. 

(a)  Empty  blood-vessels  by  heavy,  even  stroking  from  wrist 
to  elbow.     The  patient's  elbow  rests  on  the  table.     With  one 
hand  on  each  side  and  using  hands  alternately,  give  three  move- 
ments with  each. 

(b)  Empty  blood-vessels  from  elbow  to  shoulder,  sweeping 
well  over  shoulder.     With  hands  in  the  same  position  and  alter- 
nating as  for  forearm,  give  three  movements  with  each. 

4.  Percussion.     With    one    hand  on  each   side  of  the  arm, 
which  is  held  up  by  the  patient,  and  with  hands  working  to- 
gether, give  percussion  from  shoulder  to  fingers  and  return. 
Give  twice.     Place  the  patient's  arm  on  the  table  at  his   side, 
give  percussion  down  and  up  to  external  surface  as  far  as  hand. 

5.  vStroking,  three  times. 

LEGS 

1.  Leg    flexed    and    foot  flexed.     Placing  one  hand    on    the 
sole,  the  other  on  the  dorsum  of  the  foot,  give  light,  quick, 
to-and-fro  friction  transverse  of  foot.      Then  placing  the  foot 
flat,  continue  with  rapid  strokes  to  the  sides  of  the  foot,  the  leg 
arid  front  of  the  thigh.     Glide  hands  to  knee;  quick  strokes  to 
back  of  thigh;  glide  to  toes. 

2.  Apply  lubricant  with  long  strokes  to  back  of  leg  and  front 
of  thigh,  coming  down  to  knee  with  three  rotary  sweeps,  then 
long  strokes  to  back  of  thigh,  down  with  three   rotary   sweeps 
from  knee  to  ankle.     Give  twice. 


RUBS  AND  FRICTIONS  427 

3.  Friction. 

Foot  {leg  extended). 

(a)  Borsum  with  one  hand,  three  times. 

(b)  Each  side  with  one  hand,  opposite  hand   supporting- 
foot;  come  well  up  back  of  ankle,  three  times. 

(c)  Sole  with  palm  of  hand,  three  times. 

(d)  Rotary  strokes  to  heel,  three  times. 
Leg  and  Thigh  {leg  flexed}. 

a.  Calf — empty  blood-vessels  by  heavy,  even  stroking-, 
hands  following-  each  other  alternately,  three  times  with  each 
hand. 

(b)  Empty  blood-vessels  under   knee,  hands  alternating, 
three  times  with  each. 

(c)  With   one  hand  on  knee  to  support  leg-,   give  heavy 
stroking-  to  front  of  leg",  beginning  at  toes,  three  times. 

(d)  Rotary  to  knee,  hands  working-  tog-ether,  three  times. 

(e)  Empty  blood-vessels  of  thigh,  beginning  with  posterior 
surface,  hands  working  together,  three  times. 

(f)  Anterior  thigh,  three  times. 

4.  Percussion.     With  one  hand  on  each  side,  give  percussion 
from  hip  to  ankle,  down  and  up.     Give  twice. 

5.  Stroking,  three  times. 

CHEST  AND  ABDOMEN 

1.  Making-  the  hands  work  together,  stroke  the  neck  down- 
ward three  times  and  give  rotary  movements  as  follows:     Three 
above  the  clavicle  and  to  shoulder;  six  from  below  clavicle  to 
level  of  elbow  (/.  <?.,  nine  down  each  side),  returning-  up  over 
median  part  of  abdomen  and  chest.     Give  once  or*  twice. 

2.  Apply  lubricant  with  long  strokes  up  center,  four  rotary 
sweeps  down  sides,  covering-  whole  surface  thoroughly.     Give 
twice. 

3.  Friction. 

(a)  Empty  blood-vessels  of  neck  and  shoulders  by  stroking 
from  back  of  ears  downward  to  chest  and  shoulders,  three  times. 

(b)  Give  strokes  from  shoulders  to  median  line  over  the 
pectorals,  three  times. 

(c)  Using-  the  thumb  and  thenar  surface,  give  heavy  strok- 


TECHNIQUE 

ing  outward  from  median  line  over  ribs  and  abdomen,  about  six 
times,  advancing  toward  the  pubes. 

(d)  Stroking  from  umbilicus  outward  and   downward  to- 
ward middle  of  Poupart's  ligament,  three  times. 

4.  Percussion  up  and  down  left  side,  the  same  on  right  side. 
Give  twice. 

5.  Stroking,  three  times. 

BACK 

1.  Light  friction  with  the  full  hand  down  spine,  hands  alter- 
nating,  three  times  each;    to-and-fro  friction,  beginning  well 
up  on  neck,  covering  shoulders,   back  and  hips.     Give  three 
times. 

2.  Apply  lubricant  with  long  strokes  up  spine,   four  rotary 
sweeps  down  sides,  twice. 

3.  Friction. 

(a)  Heavy  friction  with  full  hand  down  spine,  hands  alter- 
nating, each  three  times. 

(b)  Heavy  rotary,  full  sweep  to  shoulders,  three  times. 

(c)  From    shoulders  down,    following  the  ribs,  cross  the 
arms  stroking  toward  the  spine,  six  times. 

(d)  Lower  back — heavy  friction  upward  over  buttocks  to- 
ward spine,    three  times;   upward  on  hips,   three  times;   out- 
ward, using  thumb  and  thenar  surface  over  crest  of  ilium,  three 
times. 

4.  Percussion  up  and  down  on  left  side,  same  on  right  side. 
Give  twice. 

5.  Stroking. 

(a)  Full'sweeps  covering  back,  three  times. 

(b)  Slow  strokes  with  full  hand  down  spine,  six  times. 

Oil  Rub— O.  R. 

The  oil  rub  softens  the  skin  and  is  frequently  used  as  a  pro- 
tective after  sweating  treatments.  It  may  be  given  in  the 
same  manner  as  the  centripetal  friction,  omitting  procedure 
number  one  (light  friction)  and  procedure  number  four  (per- 
cussion). If  desired,  the  following  abbreviated  method  may  be 
used,  always  omitting  the  percussion  after  hot  treatments. 


RUBS  AND  FRICTIONS  429 

General  Order: — 

1.  Apply  lubricant. 

2.  Rotary  friction. 

3.  Percussion. 

4.  Stroking-  (centrifugal). 

ARMS 

1.  Apply  lubricant;  beginning-  at  hands  with  a  long  stroke, 
go  over  the  arm  up  to  the  shoulder,  three  times. 

2.  Beginning  at  hand,  apply  long  stroke  up  to  shoulder,  re- 
turning with  alternate  rotary  movements,  three  each  to  shoulder, 
arm,  elbow,  forearm,  wrist  and  hand,  three  times. 

3.  Percussion  up  and  down  twice  on  external  surface.     Give 
same  on  inner  surface;  six  percussion  strokes  to  the  hand. 

4.  Finish  with  long  strokes  from  shoulder  to  fingertips,  three 
times. 

LEGS 

1.  Beginning  at  foot,  apply  lubricant  with  long  strokes  up  to 
hip  with  both  hands,  covering  the  entire  surface,  three  times. 

2.  Apply  long  strokes  from  the  foot  to  knee,  returning  with 
alternate  rotary  movements,   three  each  to  knee,   calf,    ankle 
and  foot,  twice.     Return  to  hip  with  long  stroke.     With  hands 
on  anterior  surface  of  thigh,  from  hip  to  knee,  give  eight  or 
ten  rapid  alternate  rotary  friction  movements.     Give  the  same 
on  the  posterior  surface  of  the  thigh,  three  times.     Continue 
with  rotary  friction  from  knee  down  as  at  first,  once. 

3.  Percussion  same  as  arm. 

4.  Long  stroking  movement  from  hip  to  toes,  three  times. 

CHEST  AND  ABDOMEN 

1.  Lubricate;  with  hands  working  together,  begin  at  median 
line  below,   going  lightly  up  the  median  line  and  down  the 
sides,  three  times. 

2.  Hands  working  together,  stroke  the  neck  downward  three 
times;  then  give  rotary  movements  three  each  above  clavicle, 
to  shoulder  below  clavicle,  nine  down  each  side,  nine  up  over 
median  part  of  abdomen  and  chest,  three  times. 

3.  Have  patient  take  and  hold  a  deep  breath.     Beginning 
well  over  at  lower  left  side,  give  percussion  up  that  side  to  top 


4SO  TECHNIQUE 

of  shoulder,  down  on  same  side  of  median  line,  up  on  right 
side  of  median  line  to  top  of  shoulder,  and  down  the  right  side, 
twice. 

4.  Stroking  (movement  same  as  in  lubricating),  three  times. 

BACK 

Procedure  the  same  as  for  the  chest.  Finish  with  six  long 
gentle  downward  strokes  to  spine. 

Tulcum  Rub— Talc.  R. 

The  talcum  rub  is  useful  where  oil  is  objectionable,  as  in 
warm  weather  or  where  there  is  a  tendency  to  too  free  per- 
spiration after  treatment.  It  dries  rather  than  softens  the 
skin.  It  is  also  usefiil  in  hives,  and  should  be  given  after  a 
prolonged  cool  bath.  The  procedure  is  the  same  as  with  the 
oil  rub. 

Dry  Friction — D.  F. 

The  procedure  for  dry  friction  or  the  dry  hand  rub  (d.  h.  r.) 
is  the  same  as  for  the  oil  rub  except  that  no  lubricant  is  used. 
If  given  briskly  with  vigorous  to-and-fro  friction  and  followed 
by  percussion,  the  effect  is  to  quicken  the  circulation  in  the 
skin  and  warm  the  surface.  The  treatment  also  stimulates 
heat  production. 

Slow,  heavy  friction  without  percussion,  as  to  spine,  "fore- 
head, etc.,  is  sedative. 

BATHS 

Various  procedures  more  or  less  similar  and  commonly  called 
baths  are  included  under  this  head. 

1.  PARTIAL  IMMERSION  BATHS 
Hand  and  Arm  Bath 

The  hand  and  arm  may  be  immersed  in  neutral,  hot  or  cold 
water,  or  the  two  latter  alternately.  For  this  purpose  employ 
a  foot  tub  (better  one  of  elliptical  shape)  with  sufficient  water 
to  immerse  the  hand  and  forearm  to  the  elbow,  or  including  the 
elbow.  Very  deep  pails  may  be  used.  When  hot  water  is 
used,  it  should  be  as  hot  as  can  be  borne.  Immersion  of  the 
hands  in  cold  water  is  useful  in  controlling  epistaxis. 


BATHS  431 

To  give  hot  and  cold  immersion  to  an  infected  hand  or  arm 
(blood  poisoning)  employ  two  pails  or  tubs, — one  of  the  hot- 
test water  that  can  be  borne,  and  the  other  of  ice  water  with  a 
block  of  ice  in  it.  (Plate  XI.)  To  the  cold  water  may  be 
added  one-fourth  or  one-half  dram  of  crystals  of  permanganate 
of  potassium,  and  to  the  hot  water  about  five  times  this  quan- 
tity of  oxalic  acid.  Immerse  the  hand  in  hot  water  for  one  and 
one-half  to  two  minutes,  -then  in  the  cold  for  fifteen  to  thirty 
seconds.  Continue  these  alternations  for  twenty-five  minutes 
to  an  hour,  finishing  with  the  cold.  Hot  water  should  be  added 
to  the  tub  as  fast  as  can  be  borne.  The  procedure  should  be 
repeated  from  one  to  four  times  daily  as  indicated.  Other 
parts  of  the  body,  as  the  foot,  may  be  treated  in  a  similar  man- 
ner. Massage  is  strictly  contra-indicated  in  infected  conditions. 

Foot  Bath— Ft.  B. 

The  foot  bath  is  one  of  the  most  useful  measures  in  hydro- 
therapy.  Its  chief  use  is  as  a  preliminary  or  adjunct  to  other 
treatment.  It  may  be  given  with  the  patient  lying  or  sitting, 
and  is  sometimes  given  with  the  patient  standing.  Large  pails 
may  be  used,  but  more  conveniently  tubs  of  an  elliptical  shape 
about  sixteen  inches  long  and  eight  to  ten  inches  deep. 

If  the  foot  bath  is  given  in  bed  or  on  a  treatment  table,  pro- 
tect the  bedding  or  table  coverings  with  an  oil  cloth.  Protect 
the  patient  with  a  blanket  or  sheet,  covering  the  knees  and  the 
foot  tub.  Tuck  this  covering  about  the  limbs  and  foot  tub  so 
as  to  prevent  the  circulation  of  air.  When  the  feet  are  taken 
out  of  the  water,  dry  them  thoroughly,  especially  between  the 
toes,  and  immediately  cover  well  with  dry  coverings  or  put  on 
slippers. 

1.  Hot  Foot  Bath— H.  ft.  B.  The  water  should  rise  above 
the  ankles.-  The  bath  may  be  at  a  temperature  of  about  105° 
F.,  and  should  be  gradually  increased  as  fast  as  can  be  borne 
to  a  maximum  of  about  120°  F.  It  may  be  continued  from 
five  minutes  to  half  an  hour.  At  the  close  the  feet  should  re- 
ceive a. pour  or  dash  of  cold  water  and  be  thoroughly  dried. 

It  is  often  necessary  to  use  the  cold  head  compress  if  the 
bath  is  very  hot,  continued  for  a  long  time,  or  if  given  with  the 


432  TECHNIQUE 

patient  sitting  up,  and  in  all  cases  where  there  is  a  tendency  to 
faintness. 

Effects.  The  foot  bath  is  an  efficient  means  of  securing-  a 
derivative  effect.  It  draws  blood  from  all  other  parts,  espe- 
cially those  that  are  congested.  The  cold  pour  or  douche 
given  at  the  close  helps  to  maintain  the  blood  in  the  feet.  It 
is  sometimes  desirable  to  use  a  mustard  foot  bath,  in  which  case 
add  three  or  four  tablespoonfuls  of  mustard  to  the  water. 

2.  Cold  Foot  Bath— C.  ft.  B.     The  water  should  be  from  two 
to  'four  inches  deep  at  a  temperature  of  45° — 60°  F.     The  feet 
should  be  .previously  warmed  and  during  the  bath,  rubbed  with 
the  hands  or   one    foot   by    the    other;    duration,   one  to  five 
minutes. 

Effects.  The  shallow  cold  foot  bath  causes  reflex  contraction 
of  the  blood-vessels  of  the  brain,  pelvic  organs  and  liver;  also 
contraction  of  the  muscles  of  the  uterus,  bladder,  stomach  and 
intestines.  The  cold  foot  bath  should  not  be  given  during  the 
menstrual  period  or  in  case  of  acute  pulmonary,  abdominal,  or 
pelvic  inflammation. 

3.  Alternate  Hot  and  Cold  Foot  Bath— H.  &  C.  ft.  B.    Use 
two  tubs  of  water  deep  enough  to  well  cover  the  ankles,  one  as 
hot  as  can  be  borne   (temperature  gradually  raised)    and  the 
other  at  45°  F.     Immerse  the  feet  in  the  hot  water  for  two 
minutes   and  in  the   cold  fifteen  to  thirty  seconds.     Continue 
alternations  for  ten  to  fifteen  minutes,  wiping  from  the  cold. 

Effects.  The  alternate  hot  and  cold  foot  bath  produces 
powerful  fluxion  effects  in  the  feet.  For  this  reason  the  deri- 
vation secured  by  its  use  is  very  decided  and  enduring.  It  is 
especially  useful  in  congestive  headache,  in  which  case  it  is  well 
to  apply  a  cold  compress  to  the  head  or  head  and  neck  at  the 
same  time.  It  is  also  useful  in  treating  infections  of  the  foot, 
Charcot's  joint  at  the  ankle,  tuberculosis  of  the  ankle  or  bones  of 
the  foot  and  in  gangrene  to  hasten  the  production  of  the  line 
of  demarkation. 

Leg  Bath— Lg.  B. 

For  the  leg  bath  a  tub  should  be  provided  deep  enough  to 
immerse  the  legs  to  the  knees.  (Plate  IX.)  If  used  in  the 


BATHS  433 

treatment  room  the  tub  should  be  fitted  with  an  outlet  at  the 
base  so  as  to  obviate  the  necessity  of  tipping  the  tub  over  to 
empty  it.  It  should  be  placed  near  or  against  the  wall,  so  that 
it  may  be  filled  from  a  hot  and  a  cold  water  wall  faucet  by  two 
short  rubber  hose.  Also  provide  a  stool  an  inch  or  two  higher 
than  the  tub.  The  patient  should  be  covered  with  a  sheet  or 
blanket  and,  if  the  room  is  not  warm  enough,  a  large  fomenta- 
tion cloth  or  Turkish  towel  placed  over  the  knees.  If  neces- 
sary, place  a  doubled  fomentation  cloth  under  the  knees  over 
the  rim  of  the  tub. 

1.  Hot  Leg  Bath— H.  Ig.  B.     Begin  with  the  water  at  103°  F. 
and  increase  the  temperature  as  rapidly  as  can  be  borne.     Use 
cold  cephalic  and  cervical  compresses  (or  ice  bags)  and  renew 
before  they  become  warm.     In  case  the  leg  bath  is  combined 
with  other  hot  treatment,  as  fomentations  to  the  spine,  it  may 
be  necessary  to  use  an  ice  bag  over  the  heart,  especially  if  the 
treatment  is  continued  to  profuse  perspiration.     The  treatment 
should-  be  continued  in  a  given  case  until  the  desired  effect  is 
produced.     This  may  require  from  five  to  thirty  minutes  accord- 
ing to  conditions  and  the  particular  effect  desired.     Finish  with 
a  cold  dash  to  the  legs. 

Effects.  The  hot  leg  bath  is  a  much  more  powerful  deriva- 
tive measure  than  the  hot  foot  bath  and  is  one  of  the  best  treat- 
ments that  can  be  used  for  this  purpose.  When  combined  with 
fomentations  to  the  spine  or  chest,  and  especially  when  the 
patient  drinks  some  hot  liquid  at  the  same  time,  very  profuse 
perspiration  is  produced.  If  used  in  the  home,  such  a  sweating 
treatment  should  be  concluded  by  a  cold  mitten  friction,  or  if 
given  in  the  treatment  room,  by  a  graduated  or  alternate  hot 
and  cold  shower  and  spray.  The  pail  pour  is  also  sometimes 
used  for  the  same  purpose. 

2.  Alternate  Hot  and  Cold  Leg  Bath— H.  &  C.  Ig.  B.     The 
procedure  is  the  same  as  with  the  alternate  foot  bath.     It  is 
necessary  to  apply  a  cold  compress  to  the  head  and  often  an  ice 
bag  to  the  heart. 

Effects.  The  alternate  hot  and  cold  leg  bath  produces  most 
powerful  fluxion  in  the  legs  and  feet.  It  is  especially  useful 

28 


4S4  TECHNIQUE 

in  treating-  edema  of  these  parts  whether  due  to  heart  or  kidney 
disease.  After  two  or  three  treatments  have  been  given,  pieces 
of  ice  should  be  added  to  the  cold  water.  The  treatment  may 
be  followed  by  heavy  centripetal  friction  to  the  feet  and  legs. 

Sitz  Bath— Z. 

For  the  sitz  bath  a  porcelain  sitz  tub  with  special  inlet  and 
outlet  is  the  most  satisfactory;  one  of  metal  or  an  ordinary 
wash  tub  may  be  used.  In  addition  there  should  be  a  foot  tub 
for  immersion  of  the  feet  in  hot  water.  Also  a  pail  of  cold 
water  with  a  hand  towel  for  keeping-  the  head  cool  (Plate 
XXXVIII.}. 

Protect  the  patient  from  contact  with  the  tub  by  towels  or 
fomentation  cloths  placed  behind  the  back  and  under  the  knees. 
Cover  the  patient  with  a  blanket  or  sheet.  The  temperature  of 
the  foot  bath  should  be  at  least  two  or  three  degrees  above  that 
of  the  sitz  bath. 

1.  Cold  Sitz  Bath — C.  Z.     Sufficient  water  should  be  used  to 
cover  the  hips  and  come  up  on    the    abdomen;   temperature, 
55°— 75°  F.;  foot  bath,  105°— 110°  F.;  time,  one  to  eight  min- 
utes.    Rub  the  hips  to  promote  reaction.     Friction  mitts  may 
be  used.     If  desired,  the  water  may  be  flowing-.     It  adds  some- 
what to  the  effect. 

Effects.  If  of  brief  duration  (two  to  four  minutes),  it  greatly 
stimulates  the  pelvic  circulation  and  the  musculature  of  the 
bowels,  bladder  and  uterus.  When  given  with  very  cold  water 
(55° — 65°)  and  vigorous  friction  (cold  rubbing  sitz  bath}  these 
effects  are  intensified.  The  cold  rubbing  sitz  bath  is  very  use- 
ful in  constipation,  in  subin volution  and  in  hastening  the 
absorption  of  residual  thickening  after  pelvic  inflammations. 

With  the  temperature  somewhat  modified,  it  may  be  used  in 
children  in  treating  nocturnal  enuresis. 

2.  Prolonged  Cold  Sitz  Bath— C.  Z.     Temperature,  70°— 85° 
P.;    time,    fifteen  to  forty   minutes;    foot  bath,   105°— 110°  F. 
This  may  be  begun  at  a  higher  temperature  and  very  gradually 
lowered  to  the  desired  point  (graduated  sitz  bath}.     It  should 
not  at  any  time  cause  chilliness,  and  rubbing  is  not  desirable. 


BATHS  435 

If  necessary  to  give  a  sensation  of  warmth,  a  fomentation  or 
wrapped  spinal  hot- water  bottle  may  be  applied  to  the  spine. 

Effects.  The  prolonged  cold  sitz  bath  causes  extreme  and 
lasting  contraction  of  the  pelvic  blood-vessels  and  of  the  mus- 
cular wall  of  the  uterus.  It  is  therefore  very  useful  in  subin- 
volution. 

3.  Neutral  Sitz  Bath— Neut.  Z.     Temperature,  92°— 97°  F.; 
foot  bath,   102° — 106°  F.     Apply  cool  compress  to  the  head. 
Time,  twenty  minutes  to  one  or  two  hours;  effect,  sedative. 

4.  Very  Hot  Sitz  Bath — H.  Z.     Begin   at   a  temperature  of 
about  100°  F.  and  rapidly  increase  to  106°— 115°  F.;  foot  bath, 
110°— 120°  F.     It  should  be  kept  at  least  two  degrees  hotter 
than  the  temperature  of  the  sitz  bath.     Keep  the  head  cool  by 
cold  cephalic  and  cervical  compresses;  duration,  three  to  eight 
minutes.     At  the  close  cool  the  bath  to  neutral  for  one  to  three 
minutes.     If  sweating  has  been  produced,  pour  cold  water  over 
the  shoiilders  and  chest. 

Effects.  The  hot  sitz  bath  is  used  to  relieve  dysmenorrhcea 
and  pelvic  pain  from  various  other  causes.  It  is  very  valuable 
in  both  acute  and  chronic  cystitis,  hypertrophy  of  the  prostate 
and  acute  retention  of  urine  due  to  prostatic  hypertrophy.  It  is 
also  useful  in  amenorrhrea  due  to  pelvic  anemia,  in  sciatica  and 
helpful  in  reducing  femoral  or  inguinal  hernia.  For  reducing 
hernia  the  temperature  should  not  be  lowered  at  the  close. 

5.  Revulsive  Sitz  Bath — Rev.  Z.     Begin  at  a  temperature  of 
100°  F.  and  increase  rapidly  to  106°— 115°  F.;  foot  bath,  110° 
—120°  F.     Keep  the  head  cool  by  cold   cephalic  and  cervical 
compresses.     Duration,   three  to  eight  minutes.     Finish  by  a 
cold  pail  pour  to  the  hips;  temperature  of  the  water,  55° — 65°  F. 

Effects.  The  revulsive  sitz  produces  a  fluxion  effect  in  the 
surface  and  deep  blood-vessels.  It  is  one  of  the  most  useful 
measures  in  treating  chronic  inflammatory  conditions  in  the 
pelvic  viscera  such  as  various  forms  of  salpingitis,  ovaritis, 
cellulitis,  prostatitis,  prostatic  hypertrophy,  etc. 

6.  Alternate  Hot  and  Cold  Sitz  Bath— H.  &  C.  Z.     Provide 
two  sitz  tubs  installed  side  by  side.     Fill  one  with  hot  water  at 
a  temperature  of  106° — 115°  F.  and  the  other  with  cold  water 


;..v;  TECHNIQUE 

at  55°— 85°  F.;  foot  baths,  105°— 115°  F.  Apply  cold  com- 
presses to  the  head  and  neck.  The  patient  sits  in  the  hot 
water  for  two  or  three  minutes,  then  in  the  cold  for  fifteen  to 
twenty  seconds,  and  again  in  the  hot  water.  Three  complete 
changes  from  hot  to  cold  are  made  as  is  usual  in  alternate 
treatments. 

Effects.  The  alternate  sitz  bath  produces  powerful  fluxion 
effects  in  the  pelvic  viscera.  It  is  useful  in  chronic  pelvic  in- 
flammations after  the  patient  has  become  accustomed  to  the 
revulsive  sitz.  It  may  also  be  used  to  great  advantage  in  atonic 
constipation. 

Hot  Half  Bath— H.  i  B. 

The  hot  half  bath  is  given  in  a  full  length  bath  tub.  Fill  the 
tub  with  water  at  100° — 102°  F.  and  deep  enough  to  reach  the 
patient's  navel  when  the  patient  is  sitting.  The  patient  no\v 
sits  down  in  the  tub  with  the  shoulders  covered  by  a  sheet  and 
the  head  kept  cool  by  a  cold  wet  towel  (Plate  XXXIX.}.  It  is 
usuallj-  best  to  apply  this  just  before  the  patient  enters  the 
bath.  The  temperature  of  the  bath  is  gradually  raised  to  108° 
or  110°  F.  and  "continued  for  three  to  eight  minutes.  If  nec- 
essary, an  ice  bag  should  be  used  over  the  heart.  Conclude  the 
treatment  by  a  cold  pail  pour  to  the  hips. 

The  effects  and  uses  are  the  same  as  those  of  the  revulsive 
sitz.  This  treatment  must  not  be  confused  with  the  shalloxv 
bath  which  is  given  with  cold  water,  and  is  a  tonic  measure. 

II.  FULL  IMMERSION  BATHS 

The  tub  used  for  general  or  full  immersion  baths  should  be 
long  enough  so  that  the  body  may  be  completely  immersed,— 
a  6-foot  tub  for  men,  in  many  cases  a  5^-foot  tub  is  long  enough 
for  women.  The  head  should  rest  on  an  air  pillow  or  small 
invalid  ring,  and  for  emaciated  patients,  a  folded  sheet  placed 
under  the  nates.  In  a  hot  bath,  the  head  must  be  kept  cool  by 
a  cold  compress.  In  the  case  of  full  tub  baths  it  is  especially 
necessary  that  the  temperature  of  the  water  be  tested  by  means 
of  a  thermometer.  In  ordering  tub  baths,  the  desired  tem- 
perature should  be  specified  on  the  prescription. 


PLATE  XXXVIII.     The  sitz  bath. 


PLATE  XXXIX.     The  hot  half  bath. 


BATHS  437 

Plain  Tub  Baths 

1.  Hot  Tub  Bath— H.  B.  or  H.  Tub.     Temperature,  100°— 
106°  F.;   time,   two  to   twenty  minutes.     Give    cold   water  to 
drink  freely.     Keep  the  head  cool.     If  necessary,  apply  an  ice 
bag  to  the  heart  and  the  back  of  the  neck.     It  is  usually  best 
to  begfin  the  bath  at  about  98°,  gradually  raising  the  tempera- 
ture to  the  desired  point.     The  treatment  may  be  finished  by 
cooling  the  bath,  or  by  a  cold  pour  or  shower  given  immediately 
after  rising  from  the  bath. 

Effect.  The  effect  varies  according  to  the  temperature  and 
duration  of  the  bath.  If  much  prolonged  or  the  temperature 
very  high,  profuse  sweating  is  produced.  The  hot  tub  bath 
may  be  used  as  a  preparation  for  cold  treatment.  A  warm 
bath  at  100° — 102°  is  very  effective  in  relieving  opisthotonos  in 
tubercular  meningitis  and  is  also  beneficial  in  other  diseases 
associated  with  spasticity  of  the  muscles. 

2.  Neutral  Bath— Neut.   B.     Temperature, 94°— 97°F.;  time, 
fifteen  minutes  to  three  or  four  hours;  usually  twenty  to  thirty 
minutes.     Wet  the  forehead  and  face  in  cool  water.     Cool  the 
bath  2°  or  3°  just  at  the  close.     Dry  the  patient  with  a  sheet 
directly  from  the  bath.     Use  no  percussion  or  unnecessary  rub- 
bing as  this  destroys  the  sedative  effect. 

Effects.  The  neutral  bath  is  given  for  sedative  purposes. 
To  accomplish  this,  it  must  exert  a  relaxing  effect  and  so  equal- 
ize the  circulation  as  to  reduce  the  amount  of  blood  in  the  brain 
and  spinal  cord.  Its  temperature  will  therefore  vary  with  the 
condition  of  the  patient,  especially  as  regards  the  skin  tempera- 
ture. The  season  of  the  year  must  also  be  taken  into  account. 
For  these  reasons  it  may  frequently  be  necessary  to  employ  the 
upper  limit  of  the  neutral  temperatures  or  raise  the  bath  to  98° 
or  even  99°.  The  air  of  the  bath  room  should  be  warm,  and  if 
the  bath  is  much  prolonged,  stretch  a  sheet  over  the  tub.  The 
cooling  of  the  water  2°  or  3°  just  at  the  close  is  usually  neces- 
sary to  prevent  the  slight  sensation  of  chilliness  which  is  likely 
to  be  produced  by  contact  with  the  air  on  emerging  from  the 
bath.  When  used  for  insomnia,  it  should  be  given  just  pre- 
vious to  retiring. 


438  TECHNIQUE 

3.  Continuous  Flowing  Bath.     This  requires  a  special  tub  six 
feet  long,   which  is  provided  with  a  large  outflow  and  a  large 
overflow  vent  near  the  top  (.Plate  XX.).     The  inflow  may  con- 
sist of  one  large  opening  at  the  head  of  the  tub  or  of  several 
small  openings  along  the  sides.     The  water  is  supplied  directly 
from  a  mixing  chamber  which  is  fitted  with  a  thermometer.    A 
continuous  supply  of  hot  water  at  a  constant  temperature  and 
pressure   must  be  assured,  also  of  cold  water.     The  water  is 
regulated  to  the  desired  temperature  in  the  mixing  chamber 
before   it  is   turned  into  the  tub.     The  usual  temperature  is 
98°  F.     When  the  tub  is  full  and  overflowing  the  quantity  is 
reduced  to  a  gentle  stream.     The   patient  rests  on   a  canvas 
hammock  which  swings  from  the  rim  of  the  tub;  he  is  protected 
by  a  canvas  cover  and  provided  with  a  rubber  air  pillow.     An 
ice  turban  should  be  placed  upon  his  head  and  he  should  be 
given  cold  water  plentifully  to  drink.     It  is  well  to  keep  a  bath 
thermometer  in  the  tub  and  consult  it  frequently,  not  relying 
wholly  upon  the  thermometer  in  the  mixing  chamber. 

As  this  bath  is  used  chiefly  in  maniacal  cases,  the  patient 
must  be  watched  constantly.  Very  excited  or  violent  patients 
should  be  wrapped  in  a  sheet  or  blanket  pack,  which  must  be 
securely  pinned  about  them,  and  then  placed  in  the  tub.  The 
duration  of  the  bath  depends  upon  the  degree  of  sedative 
effect  obtained.  It  may  last  for  hours  or  days.  In  the  latter 
case  the  patient  must  be  removed  once  or  twice  in  the  twenty- 
four  hours,  the  bowels  given  proper  attention  and  the  skin  an- 
nointed  with  oil  to  prevent  too  great  maceration.  The  continu- 
ous flowing  bath  is  perhaps  the  most  useful  treatment  in  ex- 
cited cases  of  insanity.  It,  together  with  the  wet  sheet  pack, 
has  revolutionized  the  treatment  of  mania. 

4.  Cold  Bath— C.  B.  or  C.  Tub.     Temperature,  55°— 90°  F.; 
time,  a  plunge  only  to  twenty  or  more  minutes,  depending  on 
the  temperature  and  effect  desired.     It  is  necessary  to  employ 
rubbing  constantly  or  at  frequent   intervals.      The    patient's 
face  should  be  bathed  in  cold  water  before  entering  the  bath, 
and  it  is  imperative  that  the  skin  be  warm  before  the  bath  is 
given. 

Effects.     When  given  to  a  patient  with  a  normal  temperature 


BATHS  439 

and  lasting  for  a  few  seconds  or  minutes  only,  the  effect  is  that 
of  a  stimulant  and  tonic.  The  cold  rubbing  bath  is  the  most 
commonly  employed  method  of  treating- typhoid  fever  in  institu- 
tions where  tubs  are  available  and  convenient  to  use.  The 
strict  Brand  bath  is  too  severe  a  measure  for  many  patients. 
The  methods,  indications  for  and  the  precautions  in  the  use  of 
the  cold  bath  have  been  very  fully  discussed  under  the  treat- 
ment of  typhoid  fever,  q.  v. 

5.  Brand  Bath.     As  advised  by  Brand  for  the  treatment  of 
typhoid  fever  the  procedure  is  as  follows: — 

Temperature,  65° — 70°  F.  Bathe  the  face  and  head  in  cold 
water  or  ice  water.  Lift  the  patient  into  the  bath.  He  should 
be  rubbed  constantly  to  keep  the  blood  in  the  skin.  If  chilling- 
carl  not  be  prevented  by  vigorous  rubbing,  the  patient  must  be 
removed  from  the  bath.  Time,  fifteen  minutes.  Repeat  when 
the  temperature  reaches  102.5°  or  103°  F.  Effect,  antipyretic. 

6.  Graduated   Bath — Grad.    B.      The  graduated  bath  is  as 
efficient  in  lowering  febrile  temperature  when  much  prolonged 
and   is  less  objectionable   to  the  patient  than  the  Brand  bath. 
As  the  bath  is  frequently  used  in  typhoid,  the  patient  should  be 
made    comfortable    by   an    air  pillow  and  hammock  made  by 
tying  a  sheet  across   the   tub  fastening  the  corners  and  sides 
underneath.     Temperature,  begin  at  98°  or  above,  depending 
on   the   height  of  the   fever,  i.  <?.,  from   3° — 5°  lower  than  the 
mouth  temperature.     The  skin  must  be  warm  to  begin  with. 
Apply  cold  compresses  to  the  head.     Gradually  reduce  the  tem- 
perature of  the  bath  to  about  85°  F.;  when  below  90°  F.  or  if 
the    patient   feels    chilly   or  shows  goose   flesh,  he   should  be 
rubbed  constantly  to  keep  the  blood  in  the  skin,  and  so  prevent 
or  overcome  chilling.     A  spine  bag  filled  with  hot  water  may 
be  laid  along  the  spine  for  the  same  purpose.     Both  pulse  and 
temperature  should  be  closely  watched  during  the  bath.     The 
temperature   of  the   patient   should  be  taken  every  twelve  or 
fifteen  minutes.     On  removal,  immediately  wrap  the  patient  in 
a  sheet,  drying  quickly,  and  if  there  is  goose  flesh  or  chilliness, 
rub  briskly  with  the  hands  until  the  blood  returns  to  the  skin. 
If  very  cyanotic,  put  the  patient  into  a  hot  blanket  pack  for  a 
few    minutes   and  take  him  out  with  a  cold  mitten  friction. 


UO  TECHNIQUE 

Effect,  tonic  chiefly  or  antipyretic  according:  to  the  condition  in 
which  it  is  given. 

7.  Cold  Shallow  Bath— C.  S.  B.  Fill  the  tub  four  to  six 
inches  deep  with  water  at  65° — 75°  F.  The  patient's  feet 
should  be  warm  before  entering:,  and  the  head  kept  cool  by  cold 
wet  towels.  The  patient  sits  down  in  the  cold  water  and  rubs 
the  arms,  legs  and  chest  vigorously  while  the  attendant  rubs 
the  hips  and  back.  Cold  wrater  dipped  from  the  tub  is  dashed 
over  the  shoulders  and  back,  and  these  parts  are  again  rubbed. 
The  patient  now  lies  down  in  the  bath  and  rubs  the  chest  and 
abdomen,  while  the  attendant  rubs  the  legs.  This  procedure 
may  be  repeated  once  or  twice  if  desired. 

The  entire  treatment  should  last  from  two  to  four  minutes, 
and  on  emerging  from  the  bath,  the  skin  surface  should  be  in  a 
decided  glow,  otherwise  the  proper  effect  has  not  been  obtained. 
The  cold  shallow  bath  is  one  of  the  most  vigorous  tonic  meas- 
ures employed  in  hydrotherapy. 

Hydro-Electric  Baths 

In  giving  the  hydro-electric  or  electrothermal  bath  a  neutral 
temperature  is  usually  employed.  The  patient  is  completely 
immersed  in  the  water  with  the  head  on  an  air  pillow  and  kept 
cool  by  a  cold  wet  towel.  The  electrodes  should  hang  from  the 
side  of  the  tub,  so  they  may  be  placed  in  any  desired  position 
along  the  sides  or  at  the  feet  of  the  patient.  The  treatment  is 
begun  with  one  electrode  at  the  feet  and  the  other  near  the  arm 
on  the  opposite  side.  The  electricity  is  turned  on  to  comfort- 
able tolerance.  Time,  five  to  twenty  minutes.  After  half  the 
time  has  expired  the  electrode  should  be  reversed,  the  one  at 
the  foot  of  the  tub  being  brought  up  along  the  arm  of  same 
side,  and  the  other  near  the  opposite  arm,  being  placed  at  the 
foot  on  the  same  side.  These  directions  do  not  apply  to  the 
galvanic  bath.  In  using  galvanism  the  positive  pole  should  be 
placed  at  the  head,  preferably  dipping  into  the  water  under- 
neath the  pillow,  and  the  negative  pole  at  the  feet. 

Precautions.  To  avoid  shock  there  should  be  no  current  pass- 
ing when  the  patient  steps  in  or  out.  Be  sure  all  appliances 
are  in  good  order  before  the  patient  enters  the  bath.  Keep  all 


BATHS  jut 

parts  of  the  generator  or  battery,  switches,  rheostat,  etc., 
absolutely  dry  and  clean.  Do  not  handle  the  switches  or  the 
rheostat  with  wet  hands. 

In  using  a  motor  generator  for  sinusoidal  or  galvanic  tub 
baths,  do  not  start  or  stop  the  generator  or  turn  the  current  on 
or  off  while  the  rheostat  is  turned  on.  After  the  patient  enters 
the  bath,  the  current  switch  is  turned  on  and  the  motor  or 
generator  started;  next  gradually  increase  the  current  by  turn- 
ing the  rheostat.  Before  the  patient  leaves  the  bath  turn  off 
the  current  by  reversing  these  steps,  i.e.,  first  gradually  lessen 
the  current  by  turning  down  the  rheostat  then  stop  the  genera- 
tor and  turn  off  the  switch. 

1.  Faradic  Tub  Bath — Neut.  Farad.  The  induction  coil  used 
should  be  large  enough  to  amply  supply  any  current  strength 
needed  and  the  interrupter  so  arranged  as  to  give  any  desired 
rate  of  vibration,  at  least  both  slow  and  rapid  interruptions 
should  be  provided  for. 

Effects.  Slow  or  medium  faradic  for  five  or  six  minutes  is 
stimulating  and  tonic.  It  is  beneficial  in  flaccid  paralysis  and 
in  general  atonic  conditions  of  the  muscular  system.  Rapid 
faradic  given  with  less  current  strength  and  continued  for 
twelve  or  fifteen  minutes  is  sedative.  The  faradic  tub  bath  is 
less  satisfactory  than  the  sinusoidal  as  the  alternations  of  the 
current  are  sharp  and  therefore  less  agreeable  to  the  patient. 

2.  Sinusoidal  Tub  Bath — Neut.  Sinu.     For  the  production  of 
a  sinusoidal  current  the  sinusoidal  dynamo  devised  by  Kellogg 
is  the  most  satisfactory.     The  slow  sinusoidal  current  gives  a 
maximum  muscular  contraction  with  a  minimum  of  unpleasant- 
ness.    The  contraction  of  the  muscles  is  vigorous  and  painless. 

Effects.  The  slow  sinusoidal  for  five  or  six  minutes  is  stimu- 
lating and  tonic.  Rapid  sinusoidal  for  a  longer  time  is  seda- 
tive. The  slow  sinusoidal  is  useful  in  all  forms  of  flaccid 
paralysis,  atrophied  muscles,  weak  abdominal  muscles,  splanch- 
noptosis,  etc.  It  is  much  more  agreeable  to  the  patient  and 
more  efficient  than  faradic  electricity,  and  for  these  reasons 
should  replace  the  faradic  wherever  possible. 

3.  Galvanic  Tub  Bath — Neut.   Galv.      Unless  given  from  a 
battery  of  cells  or  a  small  dynamo  not  connected  with  a  light- 


442  TECHNIQUE 

ing  system,  galvanic  electricity  is  dangerous.  Even  then  burns 
may  result  if  carelessly  used.  Its  administration  should  not  be 
entrusted  to  a  nurse  unless  specially  trained  in  the  technique 
and  possessing  the  requisite  knowledge  of  the  physics  of  the 
galvanic  current.  Moreover  the  effects  usually  sought  from  the 
galvanic  tub  bath  may  be  obtained  in  other  ways  without  the 
risk  to  the  patient. 

Precautions.  In  the  use  of  the  galvanic  tub  bath  all  the  pre- 
cautions mentioned  above  should  be  carefully  observed.  The 
current  must  never  be  turned  on  before  the  patient  enters,  and 
always  be  turned  off  before  he  steps  from  the  bath.  If  this  is 
not  done  a  severe  shock  may  be  occasioned  as  the  patient  places 
one  foot  in  the  bath  with  the  other  on  a  wet  floor,  thus  making 
a  grounding  contact  through  a  cement  floor  or  worse  yet  through 
some  metal  pipe  near  by. 

Always  ascertain  the  polarity  before  the  electrodes  are  placed. 
To  do  this,  place  the  electrodes  in  water  an  inch  or  two  apart 
and  turn  the  current  on.  The  bubbles  formed  at  the  negative 
pole  are  larger  and  more  numerous  than  those  formed  at  the 
positive  pole.  Place  the  positive  pole  at  the  head  of  the  tub 
and  the  negative  at  the  foot.  Be  sure  that  they  do  not  come  in 
contact  with  the  skin  at  any  point.  Sinusoidal  and  the  second- 
ary faradic  are  alternating  currents  and  there  can  therefore  be 
no  distinction  as  to  polarity. 

Effects.  The  positive  pole  is  a  vasoconstrictor;  the  negative 
pole  a  vasodilator.  For  this  reason  the  positive  pole  decreases 
congestion,  the  negative  pole  increases  it.  The  positive  pole 
has  a  sedative  effect;  the  negative  pole  a  stimulant  or  irritant 
effect.  These  are  the  reasons  for  placing  the  positive  pole  at 
the  head  and  the  negative  pole  at  the  feet  of  the  patient.  As 
a  neutral  temperature  is  used  the  total  effect  is  decidedly  seda- 
tive. All  forms  of  the  electric  tub  bath  are  disagreeable  to 
some  persons.  These  idiosyncrasies  should  not  be  ignored. 

The  temperature  and  duration  of  the  bath  and  the  strength 
of  the  current  should  be  specified  on  the  prescription.  The 
bath  should  last  from  ten  to  fifteen  minutes  and  from  twenty  to 
thirty-five  milliamperes  be  used.  The  amperage  should  not  be 
high  enough  to  produce  an  unpleasant  sensation.  If  there  are 


BATHS  W 

saline  substances  dissolved  in  the  bath-,  the  amperage  will  run 
much  higher  before  the  same  effects  are  produced  as  with 
ordinary  water.  With  thin  subjects  a  comparatively  low 
amperage  must  be  used;  with  subjects  in  good  flesh  or  over- 
•  weight  a  stronger  current  may  be  employed. 

Medicated  Baths 

A  tub  bath  may  be  altered  by  the  addition  of  various  medica- 
ments. Such  baths  are  not  of  great  practical  importance 
except  in  a  very  limited  number  of  skin  diseases. 

1.  Saline  Bath — Sal.  B.     Add  from  three   to  five  pounds  of 
common  salt  to  the  tub  of  water  at  90° — 94°  F.;  time,  ten  to 
twenty  minutes.     The  addition  of  salt  adds  to  the  tonic  effect 
through  stimulation  of  the  peripheral  circulation  so  that  the 
water  may  be  a.  few  degrees  cooler  than  an  ordinary  neutral 
bath.     The  effect  is  similar  to  a  bath  in  sea  water. 

2.  Alkaline  Bath — Alk.  B.     Add  one-half  to  one  pound  of 
bicarbonate  of  soda  to  the  tub  of  water  at  a  neutral  temperature. 
One-fourth  pound  of  carbonate  of  soda  may  be  used.     Time, 
ten    to    twenty  minutes;   effects;  relieves  cutaneous  irritation, 
itching,  etc.     Useful  in  certain  skin  diseases,  as  eczema,  also 
in  relieving  the  itching  of  hives  and  jaundice. 

Nauheim  Bath 

The  effervescent .  or  artificial  Nauheim  bath  is  one  in  which 
the  water  is  charged  with  saline  substances  and  carbon  dioxide 
gas.  Many  different  formulae  are  used  to  prepare  such  a  bath. 
To  produce  the  carbon  dioxide  gas  in  the  bath,  it  is  necessary 
that  an  acid  come  in  contact  with  an  alkaline  carbonate,  setting 
free  the  carbon  dioxide;  or  salines  may  be  dissolved  in  the 
water  and  the  carbon  dioxide  added  from  a  generator. 

Various  proprietary  mixtures  prepared  in  cakes  are  offered 
for  use.  In  using  these,  dissolve  the  sodium  chloride  and 
sodium  bicarbonate  in  forty  or  fifty  gallons  of  water.  The 
bottom  of  the  tub  is  then  covered  with  rubber  sheeting.  On 
this  rubber  sheeting  place  the  acid  cakes.  In  about  three 
minutes,  when  effervescence  is  well  under  way,  the  patient 
should  lie  down  in  the  bath. 


444  TECHNIQUE 

A  very  complete  and  satisfactory  formula  is  the  following: — 

Sodium  carbonate  (sal  soda)  l£  Ib. 

Sodium  bicarbonate  (baking:  soda)  -      J  Ib. 

Calcium  chloride    -  3  Ib. 

Sodium  chloride  (common  salt)  2  Ib. 

Sodium  bisulphate  1  Ib. 

After  mixing:  the  first  four,  dissolve  in  a  few  inches  of  warm 
water  in  the  bottom  of  the  bath  tub.  When  thoroughly  dis- 
solved, fill  the  tub  with  water  at  the  desired  temperature.  The 
sodium  bisulphate  which  is  the  acid  part  of  the  formula,  should 
be  granular  or  finely  pounded  and  dissolved  separately  in  a 
wooden  or  paper  pail  containing  hot  water.  As  it  may  require 
some  time  for  this  to  dissolve,  it  should  be  prepared  before  the 
bath  is  to  be  given.  When  thoroughly  dissolved,  pour  into  the 
tub  and  quickly  mix  with  the  rest  of  the  water.  The  bath  is 
now  ready  for  use.  The  amounts  of  the  saline  ingredients  may 
be  gradually  increased  for  the  succeeding  baths  of  a  course. 

Three-fourths  of  a  pound  of  commercial  hydrochloric  acid 
may  be  used  in  place  of  the  sodium  bisulphate.  This  should  be 
mixed  with  two  or  three  times  its  volume  of  water,  and  after 
the  salts  are  all  dissolved  and  the  tub  filled  with  water  at  the 
desired  temperature,  the  bottle  containing  the  acid  should  be 
opened  under  the  water.  It  may  be  moved  about  to  hasten 
the  diffusion  of  the  acid  into  the  water  of  the  bath. 

The  following  is  a  simpler  and  less  expensive  formula;  it  is 
the  formula  we  usually  employ. 

Sodium  chloride      -  3    to  8    Ib. 

Sodium  bicarbonate  -    f  to  l£  Ib. 

Muriatic  acid  -  I  Ib. 

The  temperature  of  the  bath  should  range  from  85° — 94°  F. 
The  lower  temperatures  should  be  used  for  the  later  baths  of  a 
series.  The  duration  of  the  bath  should  at  first  be  from  five  to 
eight  minutes.  The  time  may  then  be  gradually  extended  to 
fifteen  or  even  twenty  minutes.  A  cold  compress  should  be 
applied  to  the  head  and  an  ice  bag  to  the  heart.  The  patient 
should  not  be  rubbed  during  the  bath.  About  three  baths  a 
week  may  be  taken  for  three  or  four  weeks.  Not  over  twenty 
baths  should  constitute  a  course. 


BATHS  445 

Effects  and  Therapeutic  Use.  The  effects  of  the  bath  are  due 
to  the  cutaneous  stimulation  of  the  vasomotors  produced  by  the 
carbon  dioxide  and  salines  dissolved  in  the  water.  The  peri- 
pheral heart  is  stimulated  and  the  cutaneous  circulation  greatly 
hastened.  The  heart  beats  slower  and  with  greater  ease.  In 
normal  individuals  there  may  be  a  fall  of  ten  or  fifteen  beats  in 
the  pulse  rate  following'  a  single  bath,  while  in  case  of  a  very 
rapid  pulse  the  decrease  may  reach  as  high  as  twenty-five  to 
forty  beats  per  minute.  Examination  of  the 'heart  after  the 
bath  in  cases  of  a  valvular  lesion  or  cardiac  dilatation  show  a 
stronger,  steadier  beat;  the  rhythm  becomes  regular,  the  sounds 
clearer,  and  certain  murmurs  may  disappear  entirely.  The 
pulse  becomes  full  and  blood  pressure  rises  20  or  30  mm.  The 
area  of  dullness  of  an  enlarged,  dilated  heart  is  often  lessened 
one-half  inch  or  more  all  around  its  border.  Both  the  cystole 
and  the  diastole  are  lengthened. 

The  Nauheim  bath  also  stimulates  metabolism  and  hastens 
the  elimination  of  gouty  toxins.  It  exerts  a  beneficial  effect 
upon  nutrition  and  is  therefore  of  much  use  in  diseases  of 
metabolism. 

If  a  course  of  baths  is  continued  too  long,  over-stimulation 
results,  passive  dilatation  of  the  blood-vessels  occurs  and  the 
heart  beats  with  less  force.  The  rhythm  is  disturbed  and  there 
will  be  palpitation.  This  may  be  guarded  against  by  keeping 
the  duration  of  the  bath  well  within  fifteen  minutes,  stopping- 
short  of  the  maximum  number  of  baths  that  may  be  used  in  one 
course,  and  by  using  the  ice  bag  over  the  heart  during  the 
treatment. 

The  heart  should  be  carefully  examined  by  palpation,  per- 
cussion and  auscultation  both  before  and  after  the  bath.  This 
will  enable  the  physician  to  prescribe  much  more  intelligent! y 
and  obviate  any  difficulty-  that  may  arise. 

The  Nauheim  bath  is  useful  in  valvular  insufficiency  and 
stenosis,  cardiac  dilatation,  hyperthyroidism  and  in  cardiac 
neuroses.  It  is  also  useful  in  Bright's  disease,  chronic  articular 
rheumatism,  gout  and  obesity.  The  bath  is  contra-indicated 
in  extreme  arterio-sclerosis,  in  aneurism  and  in  angina  pectoris. 
It  should  not  be  used  in  acute  inflammatory  diseases  nor  in  the 


446  TECHNIQUE 

acute  stage  of  endocarditis.     Some  highly  recommend  its  use 
in  locomotor  ataxia. 

Oxygen  Bath— O2  B. 

This  bath  is  similar  in  effect  and  technique  to  the  Nauheim 
bath.  It  was  introduced  by  Sarason  of  Berlin  in  1904.  In- 
stead of  carbon  dioxide,  the  bath  water  is  charged  with  oxygen 
gas.  To  produce  this,  requires  the  action  of  a  catalizer  upon 
an  oxygen-containing  chemical.  Oxygen  generators  are  also 
used  for  the  same  purpose  but  are  not  regarded  as  so  efficient 
because  of  the  larger  size  of  the  bubbles.  It  is  the  oxygen  that 
is  dissolved  in  the  water  which  produces  the  results  rather  than 
that  which  collects  as  bubbles  producing  effervescence. 

The  standard  method  of  preparing  the  oxygen  bath  is  as 
follows:  Fill  the  tub  with  sufficient  water  at  95° — 98°  F.  to 
cover  the  patient  to  his  neck.  Dissolve  in  this  300  grams  of 
sodium  perborate  (Na  BOs)  by  sprinkling  uniformly  over  the 
surface  of  the  water.  Next  add  the  catalizer,  15  grams  of 
manganese  borate  (MnsCBOa^)  by  the  same  procedure.  The 
patient  gets  into  the  water  in  one  or  two  minutes  after  the 
catalizer  has  been  put  in.  The  liberation  of  oxygen  continues 
for  fifteen  to  twenty  minutes.  The  patient  should  remain  as 
quiet  as  possible,  moving  the  limbs  only  occasionly.  The  sen- 
sation is  that  of  an  agreeable  tickling  and  prickling  about  the 
spine,  shoulders  and  limbs.  At  the  end  of  twenty  minutes 
remove  the  patient  and  dry  with  as  little  disturbance  as  pos- 
sible. If  a  brownish  sediment  remains  in  the  tub  it  may  be 
easily  rinsed  off,  if  this  is  done  immediately  after  the  bath. 

The  baths  may  be  administered  on  alternate  days  or  for  four 
or  five  days  a  week,  a  course  consisting  of  twenty  to  thirty 
baths.  The  effects  are  similar  to  those  of  the  carbon  dioxide 
bath  in  the  production  of  a  powerful  stimulation  of  the  peri- 
pheral blood-vessels.  The  oxygen  bath,  however,  differs 
essentially  in  the  following  points:  Instead  of  the  redness  of 
the  skin  produced  by  the  carbon  dioxide  bath,  there  is  either 
no  change  or  the  skin  is  paler,  the  peripheral  diversion  of 
blood  occurring  into  the  skeletal  muscles  rather  than  the  skin. 
A  lowering  of  blood  pressure  occurs  after  the  oxygen  bath 


BATHS  447 

instead  of  a  rise,  as  after  the  carbon  dioxide  bath.  For  this 
reason  it  is  indicated  in  cases  of  high  blood  pressure  and  in  car- 
diac and  renal  diseases  associated  with  increased  vascular  ten- 
sion. 

It  is  also  a  powerful  sedative  to  the  nervous  system,  and  is 
therefore  a  most  efficient  measure  in  the  treatment  of  insomnia, 
also  in  asthma,  neurasthenia  and  various  paresthesias.  Be- 
cause of  the  tendency  to  paleness  of  the  skin,  it  is  an  advantage 
to  precede  the  bath  by  some  heating-  procedure,  such  as  a  hot 
foot  bath,  fomentations  to  the  spine  or  a  short  electric  light 
bath.  For  the  same  reasons  the  bath  is  administered  at  higher 
temperatures  than  the  carbon  dioxide  bath.  For  sedative  pur- 
poses the  bath  should  be  administered  in  the  afternoon  or  early 
evening,  or  at  least  an  hour  before  retiring.  In  cases  of  hyper- 
tension reductions  in  blood  pressure  of  from  15  to  35  mm.  Hg. 
have  been  reported. 

III.  MISCELLANEOUS 
Russian  Bath 

The  Russian  bath  consists  in  the  immersion  of  the  body  in 
hot  vapor.  The  steam,  as  it  is  turned  into  the  Russian  room, 
partially  condenses  and  hangs  suspended  as  a  thick  fog.  For 
every  gram  of  steam  that  thus  condenses,  537  calories  of  heat 
are  liberated.  This  fact  accounts  for  the  intense  heating  effect 
obtained  by  the  use  of  this  form  of  hot  treatment. 

For  the  Russian  bath  provide  a  steam  tight  room  with  a 
marble  slab.  .  A  sliding  window  should  be  so  arranged  at  the 
end  of  the  slab  that  the  patient's  head  may  be  outside  of  the 
steam  room.  (Plate  XL.)  The  steam  should  enter  below  the 
slab  so  as  not  to  strike  the  patient  directly,  and  be  controlled  by 
a  valve  near  the  sliding  window  so  that  the  attendant  may 
regulate  the  amount  of  steam  and  keep  the  head  cool  at  the 
the  same  time  by  frequently  changed  cold  compresses  to  the 
head  and  neck. 

Procedure.  Move  the  bowels  by  an  enema  and  give  a  pre- 
liminary hot  foot  bath.  Have  the  patient  drink  water  before 
and  frequently  during  the  bath.  This  is  necessary  in  order  to 
provide  for  the  profuse  perspiration  which  the  treatment  should 


448  TECHNIQUE 

induce.  See  that  the  slab  is  warm;  if  not,  pour  over  it  several 
pails  of  hot  water.  Warm  the  room  to  about  100°  F.,  and 
cover  the  slab  with  a  folded  sheet. 

The  patient  is  now  assisted  onto  the  table  and  lies  on  the 
back  with  the  head  on  an  air  pillow  just  without  the  opening. 
The  window  is  lowered  and  a  towel  wrung  from  ice  water  is 
placed  about  the  neck,  or  hung  across  the  lower  end  of  the 
window  and  tucked  around  the  neck.  Another  cold  compress 
is  applied  to  the  head  and  covers  the  temporal  arteries.  A 
third  cold  compress  should  be  applied  to  the  precordia.  In 
some  cases  it  will  be  necessary  to  use  an  ice  bag  over  the  heart. 

Next  turn  on  the  steam,  gradually  raising  the  temperature  of 
the  room  to  115°  or  120°  F.  A  small  amount  of  steam  should 
be  constantly  escaping  to  maintain  the  temperature.  Change 
the  compresses  to  the  head  and  neck  frequently.  The  patient 
should  be  closely  watched  during  the  entire  time  of  the  treat- 
ment. The  bath  should  last  from  ten  to  thirty  minutes.  Just 
before  the  patient  rises  from  the  slab,  renew  the  ice  compress 
to  the  head.  Finish  the  treatment  with  a  graduated  or  alter- 
nate spray  or  shower,  or  better  still,  a  shampoo  and  graduated 
shower.  The  spray  or  shower  should  be  in  the  Russian  room 
or  only  a  few  steps  from  it.  (Plate  XL/.) 

Effects.  The  effects  of  vigorous  sweating  measures  have 
been  considered  elsewhere.  The  "washing  out  "  effect  is,  per- 
haps, the  greatest;  and  the  thoroughness  of  this  depends  very 
largely  upon  the  water  taken  before  and  during  the  treatment. 
Sweating  measures  greatly  increase  catabolism,  especially  of 
carbohydrates  and  fats.  The  products  of  nitrogenous  metabo- 
lism show  more  complete  oxidation. 

The  Russian  bath  is  of  great  service  in  obesity,  chronic 
rheumatism  with  obesity,  gout,  Bright's  disease,  autointoxica- 
tions, chronic  alcoholism,  and-  in  arterio-sclerosis  unless 
extreme.  It  is  contra-indicated  in  diabetes,  valvular  heart 
disease,  all  diseases  associated  with  emaciation  and  in  extreme 
arterio-sclerosis . 

Cabinet  Vapor  Bath 

The  principle  involved  in  the  cabinet  vapor  bath  is  the  same 
as  that  of  the  Russian  bath.  Various  water-proof  cabinets  are 


BATHS  449 

offered  for  sale.  They  are  useful  in  a  home  where  more  elabor- 
ate facilities  can  not  be  provided.  An  alcohol  stove  heats 
water  in  a  basin  under  or  near  the  stool  provided  for  the 
patient.  This  is  continued  until  the  cabinet  is  full  of  vapor, 
when  it  is  ready  to  enter.  The  patient  sits  on  the  stool  with 
the  head  outside  of  the  cabinet.  The  duration  of  the  treatment 
should  depend  upon  the  rapidity  of  vaporization  and  upon  the 
effect  desired.  The  preliminaries,  procedure  and  precautions 
to  be  taken  are  the  same  as  in  the  Russian  bath.  Conclude  the 
treatment  with  a  shampco,  cold  towel  nib,  graduated  shower 
or  other  cold  application. 

Turkish  Bath 

The  Turkish  bath  consists  in  the  immersion  of  the  body  in 
hot  air.  The  Russian  room  may  be  used  for  this  purpose  and 
conveniently  heated  by  steam  coils.  Hot  air  boxes  similar  in 
shape  and  size  to  the  upright  electric  light  cabinet  may  be  used 
(Plate  XLII.}.  The  patient  is  treated  in  the  same  manner  as 
in  the  Russian  bath.  The  head  and  neck  should  be  kept  cool 
by  cold  compresses  and,  if  necessary,  an  ice  bag  applied  over 
the  heart.  The  temperature  of  the  room  should  be  gradually 
raised  from  120°  to  about  170°  F.  The  bath  may  last  from 
fifteen  to  forty-five  minutes.  Perspiration  is  often  somewhat 
delayed,  in  which  case  brisk  friction  to  the  skin  may  hasten  its 
appearance.  If  perspiration  is  much  delayed,  the  patient  is 
likely  to  behave  badly  in  the  hot  air  bath,  and  for  this  reason 
should  be  closely  watched  until  free  perspiration  is  established. 
Owing  to  the  difficulty  with  which  some  patients  react  to  dry 
hot  air,  the  applicability  of  the  Turkish  bath  is  somewhat  more 
limited  than  that  of  the  Russian  bath. 

The  Turkish,  or  hot  air  bath,  is  of  very  great  service  in 
chronic  Bright' s  disease.  It  may  be  used  daily.  It  lessens 
nephritic  dropsy  both  directly  through  increased  perspiration 
and  indirectly  by  aiding  kidney  elimination. 

Superheated  Air  Bath 

In  the  superheated  air  bath  the  temperature  reaches  250° — 
350°  F.  Special  metal  cabinets  for  the  entire  body  (Plate 

29 


450  TECHNIQUE 

XL/77.)  or  various  parts  {Plates  XV  and  XVI.}  may  be  pur- 
chased. The  body  or  part  to  be  treated  should  be  thoroughly 
wrapped  in  Turkish  toweling:  {Plate  XLIV.}  and  should  not 
rest  on  any  part  of  the  cabinet  likely  to  become  hot  enough  to 
burn.  By  means  of  a  gasoline  or  other  burner,  the  tempera- 
ture of  the  air  in  the  cabinet  is  gradually  raised  to  250°  or  350° 
F.  These  burners  are  placed  just  below  the  cabinet;  over 
them  are  fitted  inverted  funnels  with  a  short,  wide  stem  lead- 
ing; directly  into  the  cabinet.  The  entering  hot  air  should  be 
spread  by  means  of  an  asbestos  shield  so  that  it  will  not  directly 
strike  the  skin  surface.  The  patient's  pulse  and  general  con- 
dition must  be  watched  very  closely  in  giving  a  full  hot  air 
bath.  An  ice  bag  should  be  kept  on  the  heart  and  ice  com- 
presses on  the  head  and  neck.  These  precautions  are  not  so 
necessary  where  only  a  single  part,  such  as  the  knee  or  foot 
and  ankle  are  being  treated.  The  treatment  may  be  concluded 
by  an  alcohol  or  witchhazel  rub.  Great  care  must  be  exercised 
that  the  patient  does  not  take  cold  afterward.  The  Turkish 
toweling  with  which  the  body  or  limb  is  wrapped  quickly 
absorbs  the  perspiration,  thus  preventing  its  collecting  on  the 
skin  in  drops.  Should  it  collect  in  drops,  burning  is  more 
likely  to  result. 

Effects.  The  superheated  air  bath  is  a  much  more  vigorous 
measure  than  the  Turkish  bath.  It  is  of  special  advantage  in 
articular  rheumatism,  whether  occurring  in  acute  rheumatic 
fever,  chronic  gouty  rheumatism  or  in  specific  arthritis.  Where 
one  or  two  joints  are  being  treated,  the  application  should  con- 
tinue from  twenty  minutes  to  an  hour  after  the  temperature 
has  reached  300° — 350°  F.  When  the  part  is  taken  out  a  mo- 
mentary dash  of  cold  water  may  be  given  or  the  part  cleansed 
from  perspiration  and  a  heating  compress  applied.  In  gono- 
rrheal  rheumatism  this  treatment  may  be  followed  by,  or  alter- 
nate with,  the  prolonged  ice  pack,  i.  e.,  prolonged  to  about  one 
hour's  duration. 

Electric  Light  Bath— E.  L.  B. 

In  giving  the  electric  light  bath,  special  upright  or  reclining 
cabinets  fitted  with  mirrors  and  incandescent  lights  are  used. 
(  Plates  XL  VI  and  XL  VII. ) 


PLATE  XLII.     Row  of  hot  air  cabinets  for  Turkish  bath.     (Dieffenbach.) 


PLATE  XLIII.     Superheated  dry  hot  air  bath  ready  for  use. 


PLATE  XLIV.     Superheated  dry  hot  air  bath.     Patient  in  Turkish  towelinj 
suit  ready  to  be  slid  into  cabinet. 


PLATE  XLV.     Superheated  dry  hot  air  cabinet  in  use. 


BATHS  451 

The  feet  should  be  warmed  beforehand,  or  with  the  upright 
cabinet  a  hot  foot  bath  should  be  used.  Cover  the  stool  with  a 
folded  Turkish  towel.  Turn  on  the  desired  number  of  lights; 
when  the  cabinet  is  warmed,  have  the  patient  enter.  Then 
close  the  cabinet  and  apply  a  cold  wet  towel  to  the  head  and 
neck.  Renew  this  frequently.  If  there  is  a  tendency  to  faint- 
ness  or  rapid  pulse,  tise  an  ice  bag  to  the  heart  as  well.  If  a 
horizontal  cabinet  is  used,  cover  the  table  with  a  folded  sheet. 
Warm  the  cabinet  and  place  a  rubber  pillow  for  the  patient's 
head.  The  patient  then  lies  down  and  is  rolled  into  the 
cabinet,  or  the  top  is  lowered  according  to  the  style  of  cabinet 
used.  The  patient's  'head  should  be  kept  cool  by  cold  com- 
presses. There  is  less  tendency  to  fainting  with  the  horizontal 
than  with  the  upright  cabinet. 

The  patient  must  be  watched  very  carefully  and  constantly 
in  order  to  guard  against  fainting.  On  leaving  the  cabinet,  a 
blanket  or  sheet  .should  be  thrown  about  the  patient  if  it 'is 
necessary  to  go  more  than  a  few  steps  for  the  next  part  of  the 
treatment.  Finish  with  a  spray  or  shampoo  and  spray.  Where 
only  general  tonic  effects  are  desired,  the  electric  light  bath 
should  last  from  three  to  five  or  six  minutes;  for  profuse  sweat- 
ing and  eliminative  effects,  continue  it  from  ten  to  eighteen  or 
twenty  minutes. 

Effects.  The  incandescent  electric  light  is  not  so  much  a 
generator  of  actinic  rays  as  of  heat  rays.  It  is  said  that  only 
five  to  eight  per  cent  of  the  radiant  energy  of  the  incandescent 
light  consists  of  actinic  rays,  while  ninety-two  per  cent  is  in  the 
form  of  heat  rays.  For  this  reason  the  use  of  blue  globes  adds 
nothing  to  the  chief  effect  of  the  bath,  but  rather  detracts  from 
it,  since  the  volume  of  the  heat  rays  is  lessened..  The  incan- 
descent electric  light  bath  is  not  a  phototherapeutic  but  a 
thermotherapeutic  appliance. 

The  air  of  the  cabinet  is  not  warmed  to  the  same  extent  as 
the  skin  of  the  patient,  since  the  heat  is  in  the  form  of  radiant 
energy.  In  this  particular  the  electric  light  bath  differs 
essentially  from  the  Russian  or  Turkish  bath  and  from  the 
effect  produced  by  hot  applications  applied  directly  to  the  skin. 
This  means  that  the  heat  of  the  electric  light  is  not  communi- 


452  TECHNIQUE 

cated  to  the  body  by  direct  conduction  or  by  convention,  but  by 
absorption  of  the  rays  of  radiant  energy  as  they  are  retarded 
and  stopped  by  the  skin  and  subcutaneous  tissues. 

On  the  other  hand,  for  strong-  derivative  effects,  the  electric 
light  bath  is  unsatisfactory.  For  derivative  purposes  the  heat 
must  be  brought  in  actual  contact  with  the  skin  by  applying 
the  heated  substance  directly  to  the  skin.  For  this  reason, 
stronger  derivative  effects  are  secured  by  partial  or  full  hot 
baths  and  hot  packs. 

The  uses  of  the  electric  light  bath  are  numerous  and  con- 
siderable space  would  be  required  merely  to  enumerate  them. 
However,  it  is  of  special  advantage  in  Bfight's  disease,  arterio- 
sclerosis, lead  poisoning  and  other  toxemias,  obesity,  gout, 
acute  and  chronic  rheumatism,  neurasthenia,  diabetes,  skin 
diseases  and  also  for  general  tonic  and  sudorific  effects.  It 
seems  to  be  almost  a  specific  in  treating  morphine  habitues. 
They  obtain  from  it  more  relief  than  from  any  other  measure. 

SHAMPOOS 
Swedish  Shampoo — Ssh. 

For  giving  the  Swedish  or  slab  shampoo,  provide  a  pail  of 
water  at  103° — 105°  F.  on  a  stool  of  convenient  height  near  the 
head  of  the  slab,  also  a  shampoo  brush  and  a  half  bar  of  soap. 
If  the  slab  is  not  kept  warm  by  being  in  a  warm  room,  pour 
over  it  two  or  three  pails  of  hot  water.  Cover  the  slab  with  a 
doubled  sheet  and  assist  the  patient  onto  the  slab,  placing  the 
head  on  an  air  pillow.  Quickly  lather  an  arm  by  dipping  the 
brush  and  soap  in  the  pail  of  hot  water  and  rubbing  together 
over  the  part.  With  brisk  short  movements  go  over  the  part 
thoroughly,  using  as  much  friction  as  is  comfortably  borne. 
Do  the  same  with  the  chest,  abdomen  and  legs. 

Next  assist  the  patient  to  turn  over  on  the  slab  by  putting 
one  arm  under  the  neck  and  grasping  the  opposite  shoulder, 
and  the  other  arm  under  the  near  leg  and  grasping  the  oppo- 
site knee.  Treat  the  back,  hips  and  backs  of  the  legs  in  the 
same  manner  as  the  front  of  the  body.  Pour  the  remaining 
water  in  the  pail  over  the  patient  to  rinse  off  the  soap  suds. 
'Follow  the  shampoo  by  a  warm  and  cold  shower  or  spray. 


PLATE  XLVI.     Electric  light  bath  cabinet  (upright  form)  ready  for  use. 


SHAMPOOS  453 

Tub  Shampoo-^Tub  Sh. 

Fill  a  bath  tub  with  water  at  98°  F.  The  patient  may  sit  on 
a  wooden  stool  in  the  tub  or,  if  likely  to  chill,  he  should  lie 
down  in  the  tub  with  the  water  deep  enough  to  cover  the  chest. 
If  given  with  the  patient  sitting- on  a  stool,  begin  with  the  arms, 
back,  chest  and  abdomen,  then  the  legs.  If  given  with  the 
patient  immersed,  raise  one  part  at  a  time  above  the  water  and 
proceed  as  usual,  having  the  patient  sit  for  the  back  and  chest. 
Finish  by  complete  immersion  in  the  tub  followed  by  a  cold 
pail  pour  or  shower. 

Turkish  Shampoo — Tur.  Sh. 

The  Turkish  shampoo  is  given  after  sweating-  baths  such  as 
the  Turkish,  Russian  or  electric  light  bath.  The  shampoo 
proper  is  preceded  by  manipulations  and  heavy  friction  to 
loosen  the  outer  epidermis  (so-called  dead  skin).  It  is  the 
most  thorough  cleansing  measure  used. 

(a)  Articles  Necessary.  Two  pails  of  water  at  90°  F.,  one  at 
100° — 105°  F.,  loofah  or  shampoo  brush,  soap,  two  Turkish 
toweling  mitts,  two  sheets  and  towels.  In  treating  women, 
the  hair  should  be  protected  by  a  rubber  cap. 

(b}  Procedure.  If  the  sweating  bath  has  not  been  taken  in 
the  shampoo  room,  it  must  be  well  heated  and  the  slab  warmed 
by  pails  of  hot  water  poured  over  it.  Cover  with  a  doubled 
sheet  and  assist  the  patient  onto  the  slab.  Place  an  air  pillow 
under  the  head. 

Manual  Rubbing.  Wet  the  face  with  water  at  90°  F.  With 
the  hands,  dash  water  over  every  part  separately,  using  long 
strokes  and  quickly  covering  the  body.  Beginning  with  the 
neck,  about  the  ears,  hair,  forehead,  over  the  nose  and  chin, 
rub  until  the  dead  skin  is  thoroughly  loosened.  Wash  off  the 
loosened  epidermis,  dipping  the  hands  frequently.  For  the 
chest  and  abdomen,  after  applying  the  water,  use  transverse 
wringing  and  re -enforced  rubbing,  covering  each  part  several 
times.  Then  wash  off  with  water.  For  the  arms  use  spiral 
friction  and  wringing;  for  the  legs,  the  same;  with  the  thumbs, 
rub  well  about  the  ankles,  soles  of  feet,  knees,  etc.  Turn  the 
patient  and  proceed  with  the  back  in  the  same  manner  as  with 


454  TECHNIQUE 

the  chest,  also  the  thighs  and  legs.     Wash  off  the  entire  sur- 
face with  water. 

Friction  Mitt.  Dip  the  mitt  in  the  second  pail  of  water  at 
90°  F.,  and  beginning-  with  the  back  and  backs  of  thighs  and 
legs,  go  over  each  part  twice  rubbing  all  thoroughly.  Then 
turn  the  patient  and  treat  the  chest,  abdomen,  arms  and  legs  in 
the  same  manner.  Wash  off  with  the  rest  of  the  pail  of  water 
at  90°  F. 

Shampoo.  Treat  each  part  as  in  the  Swredish  shampoo,  using 
hands,  a  loofah,  or  bath  brush  and  the  pail  of  water  at  105°  F. 

Finish  with  prolonged  tepid  or  cool'shower  or  spray,  and  at 
the  close  a  short  cold  spray.  Dry  thoroughly  with  sheets  and 
towels.  The  patient  should  be  careful  not  to  take  cold  after- 
ward. 

PACKS 

Packs  are  procedures  in  which  a  considerable  portion  of  the 
body  is  enveloped  in  wet  sheets  or  blankets  for  therapeutic 
purposes. 

I.  HOT  BLANKET  PACKS 

The  hot  blanket  pack  is  a  procedure  in  which  hot  blankets 
are  used  to  communicate  heat  to  the  body. 

Full  Hot  Blanket  Pack-H.  B.  P. 

(a)  Articles  Necessary.  Two  double  blankets  or  one  single 
and  one  double  blanket;  one  hot  water  bottle  and  three  spine 
bags  half  rilled  with  hot  water  at  160°  F.,  a  bowl  or  pail  of  ice 
water  with  compresses  for  the  head,  neck  and  heart;  two 
Turkish  towels;  a  tumbler,  a  drinking  tube  and  pitcher  of  hot 
water  for  drinking. 

(£)  Preliminaries.  Move  the  bowels  by  enema,  give  a  hot 
foot  bath,  and  have  the  patient  drink  hot  water. 

(c)  Procedure.  Spread  a  double  blanket  on  the  treatment 
table  or  bed.  Adjust  a  cold  compress  to  the  patient's  head 
while  his  feet  are  still  in  the  hot  foot  bath.  Fold  the  single 
blanket  or  another  double  blanket  (the  latter  holds  the  heat 
longer)  lengthwise  in  convenient  width  for  passing  through  a 
wringer  or  wringing  by  hand.  Wring  from  boiling  water, 


PACKS  455 

quickly  unfold  and  spread  out  over  the  dry  blanket  on  the  table. 

Assist  the  patient  to  lie  on  the  hot  blanket;  or  with  a  bed 
patient,  lift  onto  the  blanket.  As  quickly  as  possible  or  as 
rapidly  as  can  be  borne,  envelope  the  entire  body  except  the 
head  in  the  hot  blanket.  Place  one  spine  bag;  between  the  legs 
with  one  thickness  of  dry  blanket  between  it  and  the  moist 
blanket,  and  the  hot- water  bottle  at  the  feet.  The  other  spine 
bags  should  be  placed  along  the  sides  of  the  trunk  in  the-  same 
way  as  the  one  to  the  legs.  Tuck  both  wet  and  dry  blankets 
in  well,  especially  at  the  feet  and  about  the  shoulders  and  neck, 
so  as  to  exclude  the  air.  See  that  the  wet  blanket  comes  in 
contact  with  the  body  over  its  entire  surface,  so  that  no  air 
spaces  will  be  left.  (Plate  XL  VIII.} 

Place  cold  compresses  about  the  head  and  neck  and  protect 
the  chin  from  the  hot  blanket  by  a  soft  dry  towel.  Renew  the 
compresses  before  they  are  warmed  to  any  extent. 

For  general  sweating  effects  a  dry  blanket  may  be  placed 
between  the  patient  and  the  wet  blanket,  but  for  strong  deriva- 
tive effects  the  wet  blanket  should  come  into  immediate  contact 
with  the  skin. 

The  patient  should  perspire  in  a  short  time.  If  perspiration 
does  not  begin  in  about  ten  minutes,  give  hot  water  to  drink  or 
a  hot  foot  bath,  or  both.  In  giving  the  hot  foot  bath,  the 
blankets  should  fall  closely  about  the  tub  so  as  to  prevent  the 
circulation  of  air. 

Continue  the  pack  for  twenty  to  thirty  minutes,  /.  e.,  until  it 
ceases  to  have  a  heating  effect;  for  tonic  effects,  five  to  ten 
minutes.  Take  the  patient  out  by  a  cold  mitten  friction  or  a 
cold  towel  rub,  removing  the  blanket  from  one  part  at  a  time 
and  covering  with  a  dry  blanket  or  bedding  immediately  after. 
It  is  usually  most  convenient  to  begin  with  the  arms,  then  the 
chest  and  abdomen,  the  legs  last,  giving  the  cold  friction  to  the 
back  after  the  wet  blanket  has  been  entirely  removed. 

(a?)  Precautions.  Too  much  water  left  in  the  pack  makes  it 
feel  very  hot  at  first,  but  it  cools  more  rapidly  than  when  wrung 
nearly  dry.  For  this  reason  the  pack  should  be  wrung  as  dry 
as  possible. 

If  the  hot-water  bags  are  too  near  the  patient  (not  sufficiently 


456  TECHNIQUE 

covered)  there  is  danger  of  burns  resulting-.  If  complaint  is 
made,  they  should  at  once  be  covered  more  thoroughly. 

In  some  cases  it  is  necessary  to  use  a  cold  compress  or  an  ice 
bag'  to  the  heart. 

General  free  perspiration  should  be  induced  by  the  pack. 
Long  continued  heat  without  perspiration  results  in  harm. 

In  giving  packs  in  case  of  paralyzed  sensation,  unconscious- 
ness, under  or  soon  after  anesthesia,  in  diabetics,  dropsy  and 
the  insane,  it  is  safer  if  a  thickness  of  dry  blanket  intervene 
between  the  patient  and  the  wet  blanket.  Hot-water  bottles 
should  be  more  thoroughly  covered  and  the  water  used  in  them 
should  be  at  a  lower  temperature  than  ordinary. 

(e)  Effects.  The  hot  blanket  pack  is  a  vigorous  sweating 
measure.  It  also  produces  decided  derivation.  Any  sweating 
treatment  decreases  internal  congestion,  but  this  action  is  much 
more  marked  when  the  wet  blanket  is  placed  next  to  the  skin. 
Where  the  congestion  is  not  localized  in  some  particular  part, 
but  consists  of  a  general  internal  congestion,  a  general  sweat- 
ing treatment  is  usually  sufficient  for  its  relief.  This  is  the 
case  in  the  first  stage  of  many  fevers,  especially  the  exanthem- 
ata, in  colds,  la  grippe,  etc. 

In  uremia,  eclampsia  and  acute  Bright' s  disease,  both  sudor- 
ific and  strong  derivative  effects  should  be  secured.  In  other 
forms  of  renal  congestion  this  is  also  necessary.  In  kidney 
insufficiency  the  skin  excreted  much  larger  quantities  of  poison 
than  in  health.  Free  or  profuse  perspiration  greatly  aids  in 
this  vicarious  function.  This  effect  is  not,  however,  the  only 
one  nor  the  most  important  effect  of  sweating  measures.  The 
congestion  of  the  skin  secured  by  a  hot  pack  reduces  the  con- 
gestion and  high  blood  pressiire  in  the  kidney  so  that  it  soon 
begins  to  functionate  when  these  causes  are  removed.  The 
hot  blanket  pack  is  also  useful  in  pneumonia  and  sometimes  in 
typhoid  fever.  It  is  almost  indispensible  in  the  treatment  of 
renal  colic  and  gall-stone  colic.  In  these  conditions  the  pain 
is  decreased  immediately  the  pack  is  applied;  in  some  cases  it 
entirely  obviates  the  necessity  for  morphine,  while  in  others 
the  dose  may  be  cut  to  one-third  or  one-fourth  the  amount  that 
would  otherwise  be  required. 


PACKS  457 

Dry  Blanket  Pack— D.  B.  P. 

Sweating"  may  be  produced  by  enveloping  the  body  in  a  dry 
woolen  blanket  and  using  hot -water  bottles  in  the  same  way  as 
with  a  wet  pack.  The  same  preliminaries  should  be  observed, 
especially  the  giving  of  the  hot  foot  bath  before.  It  is  quite 
essential  that  the  patient  take  a  considerable  quantity  of  a  hot 
drink  during  the  treatment.  Hot  lemonade  is  ideal  as  it  favors 
both  diaphoresis  and  diuresis.  The  sweating  may  be  as  profuse 
as  with  the  wet  pack  but  the  derivation  is  less  efficient.  Since 
no  wet  blanket  is  used,  the  patient  may  be  first  wrapped  in  a 
dry  sheet  and  then  in  the  dry  blanket.  The  perspiration  will 
be  absorbed  by  the  sheet  and  so,  in  a  short  time,  the  effect  will 
somewhat  approach  that  of  the  sweating  wet  sheet  pack. 

Hot  Trunk  Pack— H.  Tr.  Pk. 

The  method  of  applying  the  hot  trunk  pack  is  the  same  as 
with  the  full  blanket  pack.  The  wet  blanket  should  include  the 
pelvis  but  exclude  the  arms,  reaching  up  to  the  axilla.  The 
outside  dry  blanket  should  include  the  whole  body  but  be  used 
only  for  protection;  it  should  not  be  wrapped  tightly  about  the 
patient.  It  is  usually  best  to  apply  a  large  dry  fomentation 
cloth  between  the  patient  and  the  wet  blanket.  Place  a  hot- 
water  bottle  over  the  abdomen  between  the  folds  of  the  dry 
blanket,  and  spine  bags  on  either  side  of  the  trunk.  A  hot  foot 
bath  should  begin  before  and  continue  during  the  pack.  Time, 
twenty  to  thirty  minutes.  If  given  for  the  relief  of  the  pain  of 
any  form  of  colic,  omit  the  cold  friction  at  the  close. 

The  hot  trunk  pack  has  the  same  general  effect  as  the  hot 
blanket  pack.  Since  it  covers  less  surface  the  derivative  effects 
are  less.  It  is  especially  useful  in  digestive  disturbances  and 
in  relieving  the  pain  of  renal  and  biliary  colic,  also  in  intestinal 
colic. 

Revulsive  Trunk  Pack — Rev.  Tr.  Pk. 

The  revulsive  trunk  pack  consists  of  a  hot  trunk  pack  given 
as  directed  above  and  followed  by  a  wet  sheet  trunk  pack. 
Only  this  one  change  from  heat  to  cold  is  made.  The  wet 
sheet  is  wrung  from  water  at  about  60°  F.  and  applied  to  the 


458  TECHNIQUE 

trunk  after  removing-  the  wet  flannel  blanket.  The  method  is 
described  under  the  heading-  of  wet  sheet  packs. 

The  hot  blanket  should  be  removed  while  it  is  still  hot  and 
the  wet  sheet  applied  at  once  in  much  the  same  manner  as  for 
the  revulsive  compress.  The  wet  sheet  trunk  pack  should 
remain  in  place  until  the  heating-  stag-e  is  reached  when  it  may 
be  removed  and  a  cold  mitten  friction  or  alternate  hot  and  cold 
spray  douche  given  to  the  parts  covered  by  the  pack,  finishing 
with  the  same  to  the  feet.  If  desired,  the  wet  sheet  trunk  pack 
may  be  made  a  hot  and  heating  trunk  pack  by  inserting-  a  hot- 
water  coil  or  a  hot- water  bottle  over  the  stomach. 

The  revulsive  trunk  pack  is  used  for  tonic  purposes,  also  in 
chronic  congestions  of  the  liver  and  the  other  digestive  organs. 

Hot  Pelvic  Pack— H.  Pelv.  Pk. 

The  hot  pelvic  pack  is  applied  in  the  same  manner  as  the  hot 
trunk  pack.  It  should  come  well  above  the  crests  of  the  ilia 
and  include  nearly  half  of  the  thighs.  It  is  useful  in  the  relief 
of  pelvic  pain  from  dysmenorrhea,  cystitis,  proctitis,  etc.  Its 
effects  do  not  greatly  differ  from  those  of  the  hot  sitz  bath  or 
large,  very  hot  fomentations  to  the  pelvis,  both  of  which  treat- 
ments are  much  easier  to  apply. 

Revulsive  Pelvic.  Pack — Rev.  Pelv.  Pk. 

This  treatment  is  applied  in  the  same  way  as  the  revulsive 
trunk  pack.  The  cold  pack  should  be  prolonged  to  the  heating- 
stage.  The  effects  are  somewhat  similar  to  those  of  the  revul- 
sive sitz  and  hot  half  bath.  It  is  useful  in  chronic  congestions 
and  chronic  inflammations  of  the  pelvic  organs,  such  as  chronic 
metritis  and  endometritis  with  much  thickening,  also  in  sub- 
involution. 

Hot  Hip  and  Leg  Pack— H.  Hp.  &  Lg.  Pk. 

The  hip  and  leg  pack  should  include  the  feet,  legs,  thighs  and 
pelvis,  reaching  slightly  above  the  crests  of  the  ilia.  A  hot- 
water  bottle  should  be  .placed  at  the  feet  within  the  folds  of  the 
dry  blanket  and  a  spine  bag  between  the  legs.  Time,  twenty 
to  forty  minutes.  Taking  one  limb  out  at  a  time,  finish  with  a 


PACKS  tf9 

cold  mitten  friction  to  retain  the  blood  in  the  limbs,  thus  main- 
taining the  derivation  secured  by  the  hot  pack. 

Effects.  The  hot  hip  and  leg-  pack  is  one -of  the  most  efficient 
derivative  measures  used  in  hydrotherapy.  It  is  indicated  in  a 
large  number  of  conditions,  and  is  especially  useful  in  deplet- 
ing acutely  inflammed  organs  when  combined  with  the  use  of 
an  ice  bag  over  the  congested  part.  (See  hot  packs  with  ice 
bags.) 

Hot  Leg  Pack— H.  Lg.  Pk. 

The  hot  leg  pack  should  include  the  feet,  legs,  knees  and 
half  or  more  of  the  thighs.  Hot- water  bottles  are  used  the 
same  as  above.  Conclude  the  treatment  in  the  same  way. 

The  leg  pack  is  somewhat  less  effective  than  the  hip  and  leg 
pack.  It  is  used  for  the  same  purposes,  and  is  convenient 
where  it  is  undesirable  to  move  the  pelvis  in  giving  treatment. 
A  large  fomentation  may  be  used  over  the  anterior  surface  and 
sides  of  the  pelvis  at  the  same  time,  so  as  to  cover  nearly  as 
much  surface  as  the  hip  and  leg  pack. 

Hot  Packs  with  Ice  Bags 

Hot  packs,  combined  with  the  use  of  ice  bags  or  the  ice  water 
coil,  are  the  most  powerful  and  efficient  derivative  measures 
known  to  hydrotherapy.  They  are  especially  useful  in  reduc- 
ing internal  congestions,  reducing  or  aborting  local  inflamma- 
tion of  deep  parts  and  relieving  the  pain  incident  to  the  inflam- 
matory process.  For  these  purposes  they  are  used  only  in  the 
acute  stage  of  the  inflammatory  process.  The  effects  have  been 
fully  discussed  in  the  consideration  of  inflammation  and  anti- 
phlogistic effects,  q.  v. 

The  hot  pack  depletes  the  congested  part  by  drawing  the 
blood  away  to  establish  a  collateral  hyperemia  (pull  effect) 
while  the  ice  bag  drives  the  blood  away  by  reflexly  stimulating 
prolonged  and  extreme  contraction  of  the  deep  vessels  of  the 
inflamed  part  (push  effect).  (Plate  X.)  The  cold  mitten 
friction  given  at  the  close  causes  retention  of  the  blood  in  the 
skin  by  changing  the  passive  hyperemia  to  an  active  arterial 
hyperemia. 


460  TECHNIQUE 

These  treatments  are  sometimes  spoken  of  as  hot  and  cold 
packs,  but  this  designation  may  cause  confusion  with  the  revul- 
sive pack  in  which  a  cold  (heating-)  wet  sheet  pack  follows  the 
hot  blanket  pack. 

Ice  bags  may  be  used  with  the  full  pack  or  with  any  of  the 
partial  packs.  The  following  combinations  are  useful  in  the 
acute  stages  of  the  diseases  indicated: — 

APPENDICITIS — Hot  hip  and  leg  pack,  with  ice  bag  to  the 
appendiceal  rigion. 

PERITONITIS — Hot  hip  and  leg  pack,  or  leg  pack  only,  with 
an  ice  compress  or  ice  cap  to  abdomen. 

PUERPERAL  INFECTIONS  AND  ACUTE  SALPINGITIS — Hip  and 
leg  pack,  with  ice  to  pelvis  (suprapubic  region). 

PNEUMONIA — Hip  and  leg  pack  or  full  blanket  pack  with 
cracked  ice  compress  or  ice  bags  over  lobe  affected. 

MENINGITIS — Hot  leg  pack,  with  ice  cravat,  ice  cap  and  ice- 
bag  to  base  of  brain  and  upper  spine. 

MASTOIDITIS — Hot  hip  and  leg  pack  or  full  blanket  pack  with 
ice  cravat  or  ice  bag  over  the  carotid  artery,  ice  cap  to  head, 
and  fomentations  to  mastoid. 

ALVEOLAR  ABSCESS — Same  as  mastoiditis,  except  give  fomen- 
tations to  the  jaw. 

RENAL  CONGESTION — Hot  trunk  pack  or  full  blanket  pack 
with  ice  bag  to  lower  third  of  sternum. 

Other  combinations  will  suggest  themselves  to  the  resource- 
ful mind. 

Electrothermal  Pack — Elec.  Pk. 

The  electrothermal  pack  is  given  by  means  of  a  specially 
prepared  blanket  containing  flexible  resistance  wire.  If  it  is  to 
be  used  dry,  the  body  or  part  to  be  treated  should  be  wrapped 
in  a  dry  sheet  or  thin  flannel  blanket,  and  then  in  the  electric 
blanket,  and  the  electricity  turned  on.  The  amount  of  heat 
and  consequent  effect  may  be  governed  by  the  strength  of  the 
current.  If  to  be  used  wet,  wrap  the  patient  in  a  sheet  wrung 
nearly  dry  from  cold  or  tepid  water,  and  then  in  the  electric 
blanket.  The  treatment  is  concluded  by  a  cold  mitten  friction, 
spray  or  douche. 


PLATE  XLVIII.    The  hot  blanket  pack. 


PLATE  XLIX.    The  evaporating  wet  sheet  pack, 


PACKS  m 

Effects.  While  the  heat  is  not  as  intense  with  the  electric 
blanket  as  with  a  blanket  wrung  from  boiling-  water,  it  is  a 
gradually  increasing  heat,  and  so,  more  desirable  for  some 
purposes.  It  is  useful  for  geneYal  sweating  effects,  and  for  this 
purpose  may  be  used  with  or  without  the  wet  sheet.  The  dry 
pack  may  be  used  where  mild  continuous  heat  is  desired,  as 
after  an  operation.  In  this  case  it  should  usually  be  applied 
only,  to  the  legs  or  the  pelvis  and  legs.  A  Turkish  towel  should 
be  placed  so  as  to  form  a  pad  under  the  heels,  and  then  folded 
over  the  toes.  All  bony  prominences  should  be  similarly 
covered.  The  electric  blanket  may  be  used  to  reenforce  other 
packs  and  so  increase  or  prolong  the  effects. 

The  electric  blanket  should  not  be  folded  sharply  at  any  place, 
as  the  wires  are  likely  to  be  broken.  • 

II.  WET  SHEET  PACKS 

A  wet  sheet  pack  is  a  procedure  in  which  the  body  is  wrapped 
in  a  wet  sheet,  outside  of  which  is  a  dry  blanket  covering 
designed  to  regulate  the  evaporation. 

Full  Wet  Sheet  Pack— W.  S.  P. 

(a)  Articles  Necessary.  Two  blankets,  a  sheet,  a  large  hand 
towel,  a  Turkish  towel,  a  pail  of  water  at  60° — 70°  F.,  a  hot- 
water  bottle. 

(6)  Preliminaries.  The  feet  and  entire  body  must  be  warm 
before  the  pack  is  applied.  Chilliness,  cold  skin  or  cyanosis 
are  centra-indications.  In  case  the  skin  is  not  warm,  it  is 
necessary  to  give  a  hot  blanket  pack  or  some  other  general  hot 
treatment.  The  head  should  be  cooled  by  cold  compresses 
before  entering  the  pack. 

(<:)  Procedure.  Place  a  double  blanket  lengthwise  of  the 
treatment  table,  with  the  edge  opposite  the  attendant  hanging 
farther  over  the  edge  of  the  table  than  the  near  edge.  The 
upper  end  should  be  about  eight  inches  from  the  head  of  the 
table  and  cover  the  lower  third  of  the  pillow.  Wring  the  sheet 
as  dry  as  possible  from  cold  water  and  spread  out  upon  the 
blanket  so  that  its  upper  end  will  be  a  little  below  the  upper 
end  of  the  blanket.  The  patient  now  lies  down  upon  the  wet 


462  TECHNIQUE 

sheet  with  the  shoulders  three  or  four  inches  below  the  upper 
edge.  Both  arms  should  be  raised  while  one  side  of  the  sheet 
is  quickly  wrapped  around  the  body  drawing-  it  tightly  in  con- 
tact at  all  places  and  tucking  the  edge  under  the  opposite  side. 
Below  the  hips  the  sheet  is  wrapped  -around  the  leg  of  the  same 
side.  The  arms  are  now  lowered  and  the  opposite  side  of  the 
sheet  drawn  tightly  over  the  body  and  tucked  in.  The  sheet  is 
now  folded  over  the  shoulders  and  across  the  neck.  The  nar- 
rower edge  of  the  blanket  is.  drawn  tightly  around  the  body  and 
tucked  in  along  the  side.  The  wider  edge  is  disposed  of  in  a 
similar  manner,  pulling  it  tightly  to  bring  all  parts  in  close 
contact  and  the  extra  amount  wrapped  entirely  aroimd  the 
patient.  The  foot  end  is  doubled  under  the  feet.  A  Turkish 
towel  is  placed  about  the  neck  to  protect  the  face  and  neck  from 
contact  with  the  blanket  and  more  perfectly  exclude  the  air. 
An  additional  blanket  may  be  laid  over  the  patient  and  tucked 
in  along  the  sides  and  about  the  feet,  or  two  blankets  may  be 
placed  on  the  table  at  first. 

(d)  Precautions.     The  wet  sheet  must  come  in  close  contact 
with  the  body  at  all  points.     The  dry  blanket  must  effectually 
prevent   the    entrance    of   air,  otherwise    chilling   will    result. 
"Warming  up"  should  occur  promptly.     The  feet  must  be  kept 
warm  during  the  entire  treatment.     It  is  permissible  to  place  a 
hot-water  bottle  to  the  feet  to  hasten  reaction  in  case  this   is 
delayed. 

(e)  Stages.     According  to  the  degree  of  warming  the  pack 
undergoes,  it  passes  through  four  stages,  viz.,  cooling  or  evap- 
orating, neutral,  heating  and  sweating.     It  is  often  desirable  to 
prolong  the  effect  of  one  stage  so  that  this  effect  may  predom- 
inate.    Accordingly  the  treatment  is  varied  as  follows: — 

1.  Cooling  or  Evaporating  Wet  Sheet  Pack — Evap.  W.  S.  P. 

This  is  the  first  stage  of  the  pack  before  the  sheet  has  been 
warmed  to  the  temperature  of  the  body.  It  requires  from  five 
to  twelve  minutes  to  accomplish  this.  If  at  the  end  of  this  time 
the  sheet  is  removed  and  another  applied,  the  effect  is  inten- 
sified, or  the  blanket  may  be  folded  back  and  cold  water 
sprinkled  on  the  patient  over  the  wet  sheet.  In  case  of  vigorous 
patients  the  dry  coverings  may  be  omitted  entirely,  considerable 


PACKS  46g 

water  left  in  the  sheet,  and  the  patient  fanned  to  hasten  evap- 
oration, more  water  being  sprinkled  on  the  sheet  as  soon  as  it 
is  warmed  slightly.  The  electric  fan  may  be  used  where  very 
rapid  evaporation  is  desired.  (.Plate  XLIX.} 

Effects.  The  evaporating  wet  sheet  pack  is  a  powerful  anti- 
pyretic measure.  It  is  useful  in  typhoid  fever  and  in  other 
continued  fevers  where  repeated  antipyresis  is  necessary.  It 
is  usually  best  not  to  remove  the  pack  for  renewal  but  sprinkle 
on  more  cold  water.  As  in  the  use  of  the  cold  tub  bath  in 
typhoid  fever,  rubbing-  is  necessary  if  the  water  is  very  cold  or 
the  sheet  sprinkled  frequently.  This  is  known  as  the  nibbing 
wet  sheet  pack.  Percussion  should  not  be  used.  The  greater 
the  amount  of  water  applied  to  the  body,  the  strong-er  are  the 
antipyretic  effects,  and  consequently  the  quicker  is  the  tem- 
perature of  the  patient  reduced. 

If  desirable,  the  sheet  may  be  wrung-  from  hot  water,  the 
coverings  being  omitted.  This  is  spoken  of  as  a  hot  evaporating 
sheet.  It  is  useful  where  slight  chilliness  exists.  This  treat- 
ment is  not  only  antipyretic  but  also  lessens  heat  production 
because  of  the  initial  heat  and  the  consequent  atonic  reaction. 
2.  Neutral  Wet  Sheet  Pack— Neut.  W.  S.  P.  The  neutral 
stage  begins  when  the  temperature  of  the  pack  reaches  or 
slightly  exceeds  the  temperature  of  the  skin,  viz.,  about  94°  F. 
It  may  be  prolonged  by  removing  all  but  one  or  two  dry  cover- 
ings after  the  warming  up  has  well  begun.  This  allows  of 
sufficient  evaporation  to  prevent  the  accumulation  of  heat  above 
the  temperature  of  the  body.  The  protection  must  be  uniform 
and  the  entrance  and  circulation  of  air  prevented. 

Effects.  The  effects  of  the  neutral  wet  sheet  pack  have  been 
considered  under  the  treatment  of  insomnia.  A  neutral  tem- 
perature is  secured  the  same  as  in  the  neutral  bath.  The 
marked  sedative  effects  of  the  neutral  pack  are  due  more  to  the 
'derivation  secured  than  to  the  neutral  temperature.  In  normal 
sleep  there  is  a  lessening  of  the  amount  of  blood  in  the  brain 
and  a  local  decrease  of  blood  pressure.  The  neutral  pack  brings 
about  these  changes  and  so  aids  in  inducing  relaxation  and 
sleep. 

If  the  pack  is  removed  before  sleep  is  produced,  uncover  one 


464  TECHNIQUE 

part  at  a  time,  drying  thoroughly  and  wrapping  it  in  a  warm 
dry  sheet,  or  entirely  remove  the  pack  and  immediately  wrap 
the  patient  in  a  warmed  sheet,  finishing  the  drying  as  quickly 
as  possible. 

If  the  pack  is  removed  after  the  patient  has  slept,  conclude 
the  treatment  by  a  wet  hand  rub  or  cold  mitten  friction  accord- 
ing to  the  degree  of  tonic  effect  desired. 

The  neutral  wet  sheet  pack  is  also  of  use  in  the  delirium  of 
fevers,  in  mania,  epilepsy,  chorea,  infantile  convulsions  and 
various  other  agitative  neuroses.  (Plate  XXI.} 

3.  Heating  Wet  Sheet  Pack— Heat.  W.  S.  P.     The  heating 
stage  begins  when  the  warming  of  the  pack  raises  the  skin  tem- 
perature slightly  above  its  usual  degree;  it  ends  at  the  begin- 
ning of  general  perspiration  which  marks  the  establishment  of 
a  full  reaction.      For  tonic  effects  the  pack  should  continue 
about  twenty  minutes.     When  the  stage  of  a  pack  is  not  pre- 
scribed, this  treatment  is  intended. 

Effects.  Tonic  and  heating  effects  are  secured  by  it.  These 
may  be  prolonged  by  applying  cold  water  to  the  head  and  neck 
continuously  so  as  to  check  extreme  sweating.  The  chief 
effect  of  the  heating  wet  sheet  pack  is  the  production  of  deriva- 
tion. The  reaction  and  heating  up  of  the  skin,  caused  by  the 
accumulation  of  body  heat,  congest  the  skin  and  so  lessen  the 
amount  of  blood  in  the  internal  organs.  The  distinction  be- 
tween the  neutral  and.  the  heating  wet  sheet  packs  is  not  of 
great  importance.  Like  the  neutral  and  warm  baths,  the 
effects  differ  more  in  degree  than  in  kind.  Both  produce  deri- 
vation. As  used  in  insomnia  and  mania,  the  pack  is  pro- 
longed and  is  consequently  at  the  heating  stage  during  the 
greater  part  of  the  treatment. 

The  heating  pack  possesses  quite  a  range  of  usefulness  in 
securing  mild  tonic  and  derivative  effects.     It  may  be  used  in 
anemia,  chlorosis,  infectious  fevers,  convalescence  from  fever,- 
neurasthenia,  diabetes,  etc. 

4.  Eliminative  or  Sweating  Wet  Sheet  Pack— Sweat.  W.  S.  P. 
The  production  of  general  p'erspiration  marks  the  beginning  of 
the  sweating  stage.     The  sweating  -may  be  increased  or  pro- 
longed by  additional  coverings,  hot-water  bottles  placed  within 


PACKS  465 

the  folds  of  the  dry  blanket,  or  the  drinking-  of  hot  water  or 
lemonade  at  intervals.  The  cold  compresses  on  the  head 
should  not  be  very  cold  or  renewed  too  frequently  as  this 
depresses  the  thermogenic  centers  and  prevents  sweating1. 

Effects.  The  sweating  wet  sheet  pack  is  a  very  valuable 
eliminative  and  spoliative  measure.  It  is  one  of  the  most  use- 
ful means  in  the  treatment  of  the  transient  fevers  of  infants 
and  children,  in  capillary  bronchitis,  colds  and  the  grippe. 

For  purposes  of  elimination  it  is  useful  in  such  toxemias  as 
alcohol  and  nicotine  poisoning,  lead  poisoning  and  various 
auto-intoxications.  It  is  useful  in  chronic  Bright's  disease  and, 
if  not  too  prolonged,  it  may  be  used  in  jaundice.  For  spolia- 
tive purposes  it  is  useful  in  obesity  and  obese  rheumatics. 

Half  Pack  or  Heating  Trunk  Pack— 1-2  Pk. 

The  heating  trunk  pack  is  given  in  the  same  manner  as  the 
heating  wet  sheet  pack,  except  that  it  includes  the  trunk  and 
hips  only,  the  arms  and  legs  being  excluded.  A  full  blanket 
should  be  spread  out  on  the  treatment  table  and  over  this 
placed  a  sheet  wrung  from  water  at  60°  F.  and  folded  to  the 
proper  width  to  include  the  trunk  and  hips.  The  patient  now 
lies  on  the  wet  sheet  and  it  is  drawn  tightly  about  the  body. 
The  dry  blanket  is  next  folded  over  so  as  to  bring  the  wet 
sheet  in  close  contact  with  the  skin  surface.  A  moderately  hot 
foot  bath  is  given  at  the  same  time  and  continued  during-  the 
treatment.  The  dry  blanket  should  be  laid  loosely  over  the 
limbs.  The  pack  and  the  patient  should  not  be  so  thoroughly 
covered  as  to  produce  general  perspiration.  It  is  well  to  have 
a  dry  sheet  or  towels  intervene  between  the  blanket  and  the 
patient -at  all  places  not  covered  by  the  wet  pack.  For  this 
purpose  a  dry  sheet  may  be  spread  out  on  the  dry  blanket 
before  the  wet  sheet  is  placed  for  the  trunk.  The  treatment 
should  last  about  twenty  or  twenty-five  minutes  and  be  con- 
cluded with  a  cold  mitten  friction,  or  an  alternate  spray  douche 
to  the  parts  covered  by  the  pack  and  to  the  feet  and  legs. 
The  effects,  though  less  pronounced,  are  in  general  the  same 
as  those  of  the  hot  and  heating  trunk  pack,  q.  v. 

30 


466  TECHNIQUE 

Hot  and  Heating  Trunk  Pack— H.  &  Heat.  Tr.  Pk. 

This  treatment  is  the  same  as  that  previously  described  un- 
der the  heading  Winternitz  coil.  A  single  blanket  is  placed 
crosswise  of  the  treatment  table  or  bed  so  that  the  upper  edge 
may  reach  well  up  under  the  arms.  A  sheet  doubled  (in  case 
of  feeble  patients  a  single  thickness)  to  a  width  which  will 
reach  from  the  axilla  to  below  the  hips  is  wrung  from  cold 
water  and  placed  over  the  blanket.  The  patient  lies  down  on 
this  and  while  both  arms  are  raised,  one  end  of  the  wet  sheet  is 
pulled  tightly  across  and  around  the  trunk.  Over  the  epi- 
gastric and  umbilical  regions  outside  of  the  sheet,  place  a  three- 
quart  hot-water  bottle  half  filled  with  water  at  135°— 140°  F. 
(Plate  XIX.)  Wrap  the  other  end  of  the  sheet  about  the  trunk 
over  the  hot- water  bottle  and  cover  snugly  with  a  dry  blanket, 
folding  over  one  end  at  a  time.  A  Winternitz  coil  {Plate 
XVIII.)  or  an  electric  pad  may  be  used  in  place  of  the  hot- 
water  bottle.  Continue  the  treatment  from  forty  minutes  to 
two  hours.  General  sweating  should  not  be  produced.  It  may 
be  begun  half  an  hour  before  the  meal.  Take  the  patient  out 
with  a  cold  mitten  friction  or  an  alternate  spray  douche  to  the 
abdomen  and  spine. 

Effects.  The  hot  and  heating  trunk  pack  is  the  most  efficient 
hydrotherapeutic  measure  for  the  treatment  of  digestive  disturb- 
ances. It  promotes  gastric  secretion  and  gastric  digestion. 
Liver  activity  and  intestinal  digestion  proceed  more  normally. 
Excessive  or  reverse  peristalsis  (vomiting)  is  checked,  and  in 
decreased  gastric  motility  stomach  movements  are  hastened. 
Because  of  more  perfect  digestion  and  more  normal  peristalsis, 
gas  formation  is  markedly  decreased  or  entirely  checked. 

The  hot  and  heating  trunk  pack  is  indicated  in  persistent 
vomiting,  dyspepsia,  flatulence,  splanchnic  neurasthenia, 
chronic  congestion  of  the  liver  and  in  anemia  of  the  liver. 

In  cases  of  almost  complete  arrest  of  gastric  digestion  or  in 
persistent  vomiting,  the  pack  should  be  applied  about  twenty 
minutes  before  the  meal  and  continued  for  two  or  three  hours. 
A  cold  mitten  friction  should  be  given  at  the  close.  The  feet 
should  be  warmed  by  a  hot  foot  bath  before  the  treatment  and 


PACKS  467 

kept  warm  during-  the  treatment.  The  hot  foot  bath  may  be 
continued  while  the  treatment  lasts,  if  this  is  not  over  thirty 
minutes,  otherwise  it  is  well  to  dry  the  feet  and  wrap  them. in 
dry  flannel  so  that  the  patient  may  rest  more  perfectly.  For 
further  details  of  the  uses  and  effects,  see  treatment  of  atonic 
dyspepsia. 

Heating  Pelvic  Pack— Heat.  Pelv.  Pk.      v 

On  the  treatment  table  spread  a  blanket  as  for  a  full  pack. 
Next  fold  a  single  blanket  to  form  a  square  and  then  diagonally 
to  form  a  triangle.  Arrange  this  on  the  large  blanket  so  that 
the  base  is  upward  and  the  apex  downward  where  it  may  be 
folded  about  the  pelvis  when  the  patient  reclines.  Over  this 
place  a  sheet  similarly  folded  and  wrung  nearly  dry  from  water 
at  60°  F.  The  patient  now  reclines,  and  with  legs  flexed  and 
knees  separated,  the  apex  of  the  wet  sheet  is  brought  into  close 
contact  with  the  perineum  and  spread  over  the  abdomen.  With 
leg's  extended,  each  lateral  angle  of  the  wet  sheet  is  drawn 
down  tightly  across  the  hips,  lower  abdomen  and  upper  thigh. 
The  triangular  piece  of  dry  flannel  is  now  applied  in  the  same 
manner,  and  the  patient  covered  with  the  large  blanket.  Con* 
tinue  the  pack  twenty  or  thirty  minutes. 

Effect.  The  heating  pelvic  pack  is  a  mild  tonic  and  derivative 
means  the  same  as  the  heating  trunk  pack.  It  helps  to  equalize 
the  pelvic  circulation  and  reduce  congestions  of  the  pelvic  vis- 
cera. It  relaxes  hypertonic  muscles  and  stimulates  atonic 
muscles.  The  heating  pelvic  pack  is  not  used  as  much  as  the 
sitz  bath  in  the  treatment  of  pelvic  disorders.  It  is  indicated 
in  chronic  congestions  of  the  pelvic  organs,  amenorrhea, 
chronic,  metritis,  backache,  chronic  colitis,  etc.  When  used  in 
cases  of  much  pelvic  pain  or  other  pelvic  distress,  a  hot- water 
bottle  or  coil  should  be  placed  next  to  the  wet  sheet  over  the 
lower  abdomen  and  suprapubic  region  in  the  same  manner  as 
in  the  hot  and  heating  trunk  pack. 

SPRAYS  AND  DOUCHES 

A  spray  or  douche  consists  in  the  projection  of  one  or  more 
streams  of  water  against  the  body.  Many  different  appliances 


1>68  TECHNIQUE 

are  used  in  giving  these  treatments.  They  possess  such  a 
wide  range  of  adaptability  that  almost  any  desired  effect  may 
be  .produced  by  them.  For  this  reason  both  the  physician  and 
the  nurse  should  become  thoroughly  proficient  in  the  use  of  the 
spray  and  douche  controller.  For  a  description  of  the  con- 
troller, see  the  section  on  hydrotherapeutic  apparatus  also 
Plate  L  and  Figs.  67,  72. 

9 

Shower  Bath — Sh. 

A  shower  or  rain  bath  consists  in  the  projection  of  water  in 
many  fine  streams  falling  upon  the  patient.  In  the  shower 
bath  gravitation  is  the  principal  force  utilized;  the  effect,  how- 
ever, is  often  enhanced  by  added  pressure.  The  perforated 
disc  from  which  the  water  descends  should  be  about  eight 
inches  in  diameter  and  from  ten  to  sixteen  inches  above  the 
patient's  head.  There  should  be  sufficient  force  to  cause  the 
water  to  flow  rapidly.  The  room  should  be  very  small  and 
protected  from  drafts.  See  that  the  patient's  feet  are  warm 
before  entering  the  shower.  If  the  wetting  of  the  hair  is 
objectionable,  as  with  women,  protect  by  a  rubber  or  mackin- 
tosh cap,  or  with  a  shower  head  attached  by  a  ball  joint  turn 
it  forward  at  an  angle  of  forty-five  degrees.  Turn  on  the 
shower  and  adjust  to  the  proper  temperature  before  the  patient 
enters. 

1.  Hot  Shower— H.  Sh.     Begin  the  hot  shower  at  100°— 105° 
F.,  and  gradually  raise  the  temperature  to  from  110° — 115°  F., 
or    slightly    above.     Time,  one    to    five    minutes.     It    is  used 
chiefly  as  a  preparation  for  the  cold  shower  or  douche.     It  may 
be  necessary  to  use  a  cold  compress  to  the  head  during  the  hot 
shower.     If  only  a  hot  shower  is  prescribed,  cool  rapidly  to  90° 
or  85°  F.,  and  dry  quickly  with  sheet  and  towels,  finishing  by 
fanning  the  patient  with  a  dry  sheet. 

2.  Cold  or  Cool  Shower — C.  Sh.     The  cold  shower  is  usually 
preceded    by    a    hot    shower.      When    the    patient    has    been 
warmed,  lower  the  temperature  rapidly  from  hot  to  the  limit  of 
tolerance  or  reactive  ability  of  the  patient  and  maintain  at  this 
point  long  enough  for  a  vigorous  tonic  effect.     Those  who  have 
become  accustomed  to  cold  treatment  may  take  the  cold  shower 


PLATE  L.     Hydrotherapy  control  table  devised  by  the  author. 


SPRAYS  AND  DOUCHES  469 

without  the  preliminary  hot  shower.  Cool,  70° — 90°  F.;  cold, 
55° — 70°  F.  At  first,  before  the  patient  becomes  accustomed  to 
the  shower,  the  upper  limits  should  be  utilized  and  in  each 
succeeding-  treatment  the  temperature  lowered  by  1°  or  2° 
daily  and  the  time  prolonged  to  from  one-half  to  three  or  more 
minutes.  Effects,  tonic. 

3.  Neutral  Shower — Neut.  Sh.     In  giving-  a  neutral  shower, 
begin  with  the  water  at  100°  F.,  and  very  gradually  lower  it  to 
97° — 94°  F.     The  treatment  should  last  from  three  to  five  min- 
utes.    The  patient  should  be  dried  quickly  without  percussion 
or  unnecessary  friction.     Effects,  sedative. 

4.  Graduated    Shower — Grad.   Sh.      After   a   prolonged   or 
vigorous  sweating  bath  where  much  heat  has  been  communi- 
cated to  the  body,  it  is  desirable  to  lower  the  temperature  of  the 
shower  slowly  for  gradual  cooling  and  to  abstract  as  much  heat 
from  the  body  as  possible  without  producing  a  decided  thermic 
reaction.     Apply  a  cold  compress  to  the  head  before  the  patient 
leaves  the  hot  bath.     Begin  at  108° — 110°  F.,  quickly  raising 
the  temperature  to   115°  or  118°   F.     Maintain  this  until  the 
patient  feels  well  warmed  and  is  ready  to  welcome  the  cold. 
Gradually  lower  the  temperature  to  between  80°  and  90°  F. , 
maintaining-  it  at  this   point  for  from   two  to    four   minutes. 
Dry  as  quickly  as  possible  with  sheets  and  towels  and  see  that 
the  patient  is  not  exposed  to  cold  air  or  drafts  for  at  least  an 
hour  after. 

5.  Revulsive  Shower — Rev.  Sh.     Begin  the  shower  at  105°- 
108°  F.  and  gradually  raise  the  temperature  to  from  110° — 115° 
F.  or  slightly  above;  continue  at  this  point  for  one  to  two  min- 
utes.    When  the  patient  has  been  thoroughly  warmed,  turn  the 
mixer  quickly  to  cold  at  a  temperature  of  60° — 85°.     After  five 
to  ten   seconds  turn  the  mixer  valve  back  to  the  former  tem- 
perature for    one  to   two  minutes.      Three  complete   changes 
from  hot  to  cold  are  made.     After  the  last  cold,  dry  quickly 
with  sheets  and  towels  as  usual. 

Effects.  The  revulsive  shower  has  a  mild  tonic  and  stimulant 
effect.  The  patient  should  become  accustomed  to  it  before 
taking  the  alternate  hot  and  cold  shower.  The  chang-e  from 


470  TECHNIQUE 

one  to  the  other  may  be  made  gradually  by  lengthening  the 
duration  of  the  cold  with  each  succeeding  treatment. 

6.  Alternate  Hot  and  Cold  Shower — H.  &  C.  Sh.  To  obtain 
the  best  results  the  changes  should  be  abrupt  from  hot  to  cold. 
As  the  water  must  traverse  about  fifteen  feet  of  pipe  before  it 
reaches  the  patient,  an  absolutely  instantaneous  change  is  im- 
possible. Beg-in  with  the  hot  at  a  temperature  of  106° — 110° 
F.,  raising"  the  temperature  quickly  to  the  limit  of  tolerance 
and  continue  it  about  one  minute;  then  turn  the  mixer  valve 
quickly  to  cold  and  continue  fifteen  to  thirty  seconds.  Reverse 
again  to  hot  for  about  one  minute  and  follow  this  by  a  second 
cold  and  so  on  for  three  complete  changes  of  hot  and  cold, 
finishing  with  the  cold  and  drying  as  usual. 

Effects.  The  alternate  hot  and  cold  shower  is  a  vigorous  tonic 
and  stimulant.  It  should  not  be  ventured  upon  without  con- 
siderable preliminary  training  by  milder  measures.  Some  find 
it  more  agreeable  than  the  spray  and  easier  to  react  to. 

Sprays — Spr. 

A  spray  bath  consists  in  the  simultaneous  projection  of  water 
against  all  parts  of  the  body  by  horizontal  jets  surrounding  the 
patient.  For  this  purpose  four  upright  pipes,  arranged  in  a 
square  and  having  perforations  on  the  side  of  each  toward  the 
center,  are  used.  Since  these  pipes  are  stationary,  it  is  neces- 
sary to  have  a  short  patient  stand  on  a  stool  so  that  the  water 
may  not  strike  the  face.  A  tall  patient  must  bend  the  knees  in 
order  to  have  the  spray  cover  the  entire  trunk.  To  overcome 
this  inconvenience  and  to  spread  the  streams  of  water  still 
more, .four  rosettes  may  be  arranged  along  each  pipe  at  inter- 
vals of  sixteen  inches,  the  upper  row  being  moveable.  The 
effects  and  uses  of  the  spray  are  the  same  as  those  of  the 
shower,  with  the  possible  difference  that  the  application  is  some- 
what more  general  and  there  is  more  or  less  mechanical  stimu- 
lation due  to  percussion  or  pricking  of  the  jets.  This  is  greater 
as  the  pressure  is  increased  by  the  full  opening  of  the  spray 
valve.  However  this  depends  entirely  on  the  size  of  the  open- 
ings in  the  pipes  or  rosettes.  If  many  and  very  fine  the  treat- 
ment is  most  agreeable.  Hot,  cold,  neutral,  graduated,  revul- 


SPRAYS  AND  DOUCHES  471 

sive  and  alternate  treatments  are  given  in  the  same  manner  as 
with  the  shower. 

Douches — D. 

The  douche  is  a  local  application  consisting:  of  a  single  or 
multiple  column  of  water  directed  against  some  part  of  the 
body.  It  is  certainly  one  of  the  most  useful  of  all  hydrothera- 
peutic  measures.  The  effect  of  almost  every  other  form  of 
treatment  commonly  given  to  ambulatory  patients  may  be 
approached  and  usually  exceeded  by  the  douche  in  the  hands 
of  one  skilled  in  its  application.  The  necessary  attachments 
are  not  numerous.  {Figs.  70,  71.}  These  should  consist  of  a 
straight  nozzle;  a  spray  nozzle  or  rosette  like  the  sprinkler  of 
a  watering  pot  except  that  the  perforated  dish  should  have  a 
nearly  flat  face;  a  fan  douche  nozzle,  a  movable  flat  piece 
attached  to  the  straight  nozzle  will  answer  the  same  purpose; 
a  stool  with  an  open  seat  and  attached  up-shot  spray  douche 
nozzle  for  administering  the  perineal  douche. 

The  jet  nozzle  is  used  whenever  percussion  effects  are  desired. 
The  pressure  may  be  increased  by  opening  wide  the  douche 
valve,  or  by  turning  into  the  nozzle  compressed  air  from  a 
separate  tube.  Where  a  percussion  douche  (Perc.  D.)  is 
ordered,  the  jet  is  understood.  Both  cold  and  percussion  pro- 
duce a  decided  thermic  reaction  and  increase  the  vigor  and 
permanency  of  the  circulatory  reaction.  The  spray  douche 
is  useful  where  percussion  is  not  desirable.  The  jet  douche 
may  be  ' '  broken ' '  by  placing  the  finger  so  as  to  interfere  with 
the  stream.  It  then  resembles  the  spray  douche  in  effect.  The 
effects  in  general  vary  according  to  the  mass,  pressure  and 
temperature  of  the  column  of  water  striking  the  body. 

In  prescribing  douches  the  form  of  nozzle  desired  should  be 
specified  and  such  designations  used  as  will  indicate  the  part  of 
the  body  to  be  treated.  The  cerebral  circulation  will  be 
steadied  and  better  general  and  local  results  obtained  if  all 
applications  of  the  douche  begin  and  end  with  the  feet.  The 
patient  should  dip  the  hands  in  cold  water  and  bathe  his  face 
and  head  before  the  douche  is  applied.  In  applying  the  douche 
some  definite  plan  should  be  learned  and  systematically  followed, 


472  TECHNIQUE 

making;  changes  when  necessary  for  the  particular  case  and 
condition  in  hand.  In  order  to  guard  against  burning,  if  pos- 
sible, keep  the  index  finger  of  the  hand  holding  the  douche 
in  contact  with  the  stream  of  water  as  it  emerges  from  the 
nozzle.  This  should  be  done  with  the  most  perfect  of  appli- 
ances and  even  when  no  trouble  at  all  is  anticipated.  Keep  a 
steady  hand,  apply  the  douche  accurately  to  the  part  to  be 
treated  and  have  the  thermometers  under  constant  observation. 
The  following  are  the  general  directions  for  douches  of  dif- 
ferent temperatures.  In  giving  these  any  form  of  nozzle  may 
be  used  and  any  portion  of  the  body  treated.  To  enumerate  all 
the  possible  variations  and  the  particular  surface  to  be  treated 
together  with  the  reflex  or  hydrostatic  effects  derived  from  each 
would  require  a  small  volume  in  itself.  As  in  all  hydrothera- 
peutic  procedures,  practical  instruction  is  of  far  more  value 
than  any  amount  of  text  description  and  text  illustration.  Such 
designations  as  the  Scotch  douche,  Charcot  douche,  etc.,  are 
non-descriptive  and  as  far  as  possible  should  be  dropped  from 
hydrotherapeutie  nomenclature. 

In  giving  douches  it  is  essential  that  the  changes  be  abrupt 
from  hot  to  cold.  This  is  best  secured  by  two  douche  units 
each  with  its  own  mixer  so  that  both  may  be  kept  going 
during  the  entire  treatment,  the  changes  being  made  by  using 
the  two  alternately.  In  this  way  the  changes  are  absolutely 
instantaneous.  The  following  types  serve  only  as  a  general 
guide.  The  successful  physician  will  find  use  for  many  grada- 
tions between  the  revulsive  and  alternate  hot  and  cold  douche. 
The  treatment  must  be  adapted  to  each  individual  case. 

1.  Hot  Douche — H.  D.  Where  the  hot  douche  alone  is  used 
it  is  given  for  a  relatively  long  time,  two  to  five  minutes,  at  a 
temperature  of  105° — 125°  F.,  and  followed  by  a  very  brief 
application  of  cold,  five  to  fifteen  seconds;  temperature  60°- 
90°  F.  This  is  supposed  to  be  just  long  enough  to  remove 
from  the  skin  the  heat  communicated  by  the  hot  douche.  The 
principle  is  identical  with  that  of  the  revulsive  douche  except 
that  in  the  latter,  three  or  more  changes  are  employed,  while 
here  only  one  is  given  and  the  duration  is  much  longer. 

Effects.     The  hot  douche  produces  dilatation  of  the  cutaneous 


SPR A  YS  AND  DO  UCHES  473 

vessels  and  so  where  applied  to  a  considerable  area,  effective 
derivation  is  secured.  Where  applied  to  a  small  area,  the  dila- 
tation of  the  vessels  in  the  deep  part  through  a  reflex  channel 
may  equal  or  exceed  the  hydrostatic  effect.  Percussion  intensi- 
fies the  reflex  effect.  The  hot  douche  is  used  for  the  relief  of 
pain,  irritation,  neuralgia,  sciatica,  etc.  In  these  cases  per- 
cussion is  undesirable. 

2.  Neutral    Douche — Neut.    D.     Temperature,   94° — 97°   F.; 
time,  three  to  six  minutes.     The  broken  jet  or  spray  douche  is 
used    since    sedative    effects   are   sought.      The  neutral   spray 
douche  is  especially  beneficial  when   given  to  the  spine.     No 
force  should  be  used  and  the  patient  should  sit  on  a  stool  with 
the  back  to  the  operator.     If  given  properly  this  treatment  is 
essentially  a  neutral  pour. 

3.  Cold    Douche— C.  D.      Temperature,   55°— 70°   F.      The 
cold  douche  is  seldom  given  alone,  but  when  not  preceded  by 
hot,  the   percussion  jet  should  be  used.     Given   in  this  way, 
vigorous  fluxion  is  produced  in  the  part  treated  with  a  corres- 
ponding derivation  from  other  parts.     For  this  reason  it  is  very 
effective  in  relieving  cold  feet. 

4.  Revulsive  Douche — Rev.  D.     Three  abrupt  changes  from 
hot  to  cold  are  used.     Temperature  of  the  hot,  112° — 115°  F.; 
time,  a  half  to  two  minutes;  temperature  of  the  cold,  55° — 70° 
F.;  time,  five  to  ten  seconds.     Unless  given  with  high  pressure, 
(percussion)  the  reaction  is  chiefly  circulatory.     Percussion  is 
not  usually  desirable  with  the  revulsive  douche. 

Effects.  It  will  be  noted  that  the  duration  of  the  cold  is 
exceedingly  brief  as  compared  with  the  duration  of  the  hot.  In 
this  item  lies  the  difference  between  the  revulsive  and  the  alter- 
nate hot  and  cold  douche.  The  effect  of  the  re vulsive  douche 
is  chiefly  circulatory  and  greater  in  the  surface  blood  vessels 
than  in  the  deep  part,  i.  <?.,  the  reflex  effect  is  not  prominent. 
The  surface  effect  is  that  of  fluxion  and  if  a  sufficient  surface  is 
covered  by  the  treatment,  a  hydrostatic  (derivative)  effect  upon 
other  parts  is  produced. 

The  revulsive  spray  douche  is  especially  applicable  to  the 
chest,  abdomen  and  over  the  liver  and  spleen,  also  to  the  spine, 
pelvis  and  perineum. 


474  TECHNIQUE 

5.  Alternate    Hot    and    Cold    Douche— H.   &   C.   D.      The 

method  of  giving  the  alternate  douche  is  the  same  as  for  the 
revulsive  douche  except  that  the  cold  application  is  of  greater 
duration,  being  from  one-third  the  duration  of  the  hot  to  equal 
with  it,  so  that  where  the  hot  is  given  for  one  minute  the  cold 
should  last  twenty  seconds  to  one  minute,  depending  upon  the 
reactive  powers  of  the  patient.  Percussion  (H.  &  C.  Perc.  D. ) 
adds  much  to  the  vigor  and  permanency  of  the  reaction. 

Effects.  The  alternate  hot  and  cold  douche  produces  vigor- 
ous fluxion  in  the  surface  treated.  When  percussion  is  used 
the  reflex  effects  become  prominent  especially  if  the  douche  is 
applied  to  only  one  or  two  parts  of  the  body.  As  a  general 
treatment,  for  example,  the  alternate  hot  and  cold  percussion, 
douche  to  the  spine  and  legs,  powerful  tonic  and  stimulant 
effects  are  produced.  The  alternate  percussion  douche  to  the 
feet  and  legs  is  a  most  efficient  derivative  measure,  especially 
when  preceded  by  the  hot  leg  bath.  The  extreme  fluxion  it 
induces  in  the  feet  and  legs  produces  a  decided  and  enduring 
derivation. 

The  following  list  of  treatments,  which  may  be  given  by 
means  of  the  spray  and  douche  apparatus,  will  help  to  show  the 
technique  and  something  of  the  principles  involved  in  the 
effects  desired. 

As  A  GENERAL  TONIC — H.  &  C.  Perc.  D.  to  spine,  legs  and 
feet. 

To  PRODUCE  REACTION  IN  ONE  UNACCUSTOMED  TO  COLD — 
H.  Spr.  with  H.  &  C.  Perc.  D.  to  spine  and  legs  at  same  time. 

To  RELIEVE  CONGESTIVE  HEADACHE — H.  &  C.  Perc.  D.  to 
feet  with  C.  Comp.  to  head. 

PASSIVE  CONGESTION  OF  THE  LIVER — Rev.  or  Alt.  H.  &  C. 
D.  (Perc.  or  Spr.)  over  hepatic  area. 

SCIATICA — Prolonged  H.  Fan  D.  over  sciatic  nerve. 

VARICOSE  ULCERS — H.  &  C.  Spr.  D.  to  legs,  six  to  ten 
changes. 

HYPOCHLORHYDRIA — Rev.  Spr.  D.  to  epigastrium  and  H.  & 
C.  Perc.  D.  to  mid-dorsal  spine. 

LUMBAGO — H.  &  C.  Perc.  D.  to  lower  back. 


SPRAYS  AND  DOUCHES  475 

LOCOMOTOR  ATAXIA  AND  OTHER  FLACCID  PARALYSES — Alt. 
H.  &  C.  D.  to  spine. 

SPASTIC  SPINAL  PARALYSIS — Prolonged  Neut.  Spray  D.  to 
spine. 

CHOREA — Neut.  D.,  Sh.  or  Spr. 

RENAL  CONGESTION  (CHRONIC) — H.  &  C.  Perc.  D.  to  lower 
third  of  sternum  and  over  kidneys  at  back. 

CHRONIC  PELVIC  CONGESTIONS — C.  D.  or  Alt.  H.  &  C.  D.  to 
lumbar  and  sacral  regions . 

AMENORRHCEA — Short  C.  Perc.  D.  to  feet. 

SPECIFIC  URETHRITIS,  PRURITIS  ANI,  CHRONIC  PROSTATITIS, 
ETC. — Rev.  or  Alt.  H.  &  C.  Spr.  D.  to  perineum  (called  also 
"up  spray"). 

CHRONIC  PLEURISY,  UNRESOLVED  PNEUMONIA,  ETC. — Rev. 
or  H.  &  C.  Spr.  D.  to  chest  over  area  affected  (use  no  force) 
followed  by  H.  &  C.  Perc.  D.  to  feet  and  legs. 

ATONIC  CONSTIPATION — Alt.  H.  &  C.  Fan  D.  to  abdomen. 

CHRONIC  MALARIA — Alt.  H.  &  C.  D.  to  spine  and  legs; 
Alt.  Fan  D.  to  splenic  area. 

Affusions 

An  affusion  is  the  pouring-  of  water  from  a  convenient  recep- 
tacle over  the  entire  body  or  a  portion  thereof.  Since  the  per- 
fection of  the  spray  and  douche  apparatus,  the  affusion  has 
fallen  into  disuse  in  institutions  equipped  with  such  appliances. 
However,  the  pour  has  certain  advantages  which  are  not  out- 
weighed by  the  greater  convenience  of  more  complicated  appli- 
ances. The  flow  of  a  considerable  volume  of  water  over  apart 
has  a  somewhat  different  effect  from  a  douche.  Since  it  may 
be  used  in  any  home,  it  has  a  wide  range  of  usefulness. 

1.  Pail  Pour  or  General  Affusion— P.  P.  The  patient  should 
be  warm  beforehand.  If  given  in  a  bath  tub  he  may  sit,  or  if 
given  while  standing,  the  feet  should  be  in  a  tub  of  hot  water, 
and  in  either  case  apply  a  cold  cephalic  compress.  Prepare 
three  pails  of  water  at  different  temperatures,  according  to  the 
effect  desired.  These  should  be  poured  over  the  shoulders, 
using  the  warmest  first.  For  a  mild  tonic  employ  pails  of 
water  at  100°,  90°,  and  85°  or  80°  F.,  respectively.  If  the 


476  TECHNIQUE 

patient  has  just  come  from  a  warm  bath  of  some  sort,  a  lower 
temperature  may  be  used  for  the  first  pail  and  the  others  cor- 
respondingly lower,  or  only  two  pails  used.  In  succeeding 
treatments  lower  the  degree  of  the  applications  until  water  at 
50° — 60°  is  used  for  the  third  pail.  Rub  the  patient  vigorously 
after  the  last  pail  and  dry  as  from  spray  or  shower.  The  pail 
pour  is  conveniently  used  after  the  tub  or  slab  shampoo,  salt 
glow,  etc.  A  cold  pail  pour  to  the  hips  is  given  after  the  hot 
half-bath  and  the  hot  sitz  bath  for  revulsive  effects. 

2.  Local  Affusions.  These  may  be  designated  according  to 
the  part  treated  and  the  temperature  of  the  application.  A  hot 
affusion  relieves  pain.  The  circulatory  excitation  soon  gives 
way  to  an  atonic  reaction.  A  neutral  affusion,  especially  to  the 
spine,  is  sedative.  A  cold  affusion,  if  short,  is  stimulating 
and  tonic;  if  prolonged,  it  reduces  congestion  and  inflammation, 
stimulating  phagocytosis.  A  long  continued  cold  pour  to  the 
head  is  strongly  antipyretic.  The  alternate  hot  .and  cold  pour 
is  a  powerful  stimulant  and  tonic,  producing  fluxion  in  the  part 
treated,  with  derivation  from  other  parts.  It  produces  a 
decided  local  leucocytosis  and  stimulates  phagocytosis.  Because 
of  these  effects  it  is  a  very  useful  measure  in  treating  an 
infected  part  where  it  is  impossible  or  Undesirable  to  completely 
immerse  the  part  in  water. 

In  giving  an  affusion  to  the  spine,  the  patient  may  sit  on  the 
edge  of  a  bath  tub  or  on  a  stool  in  the  tub.  In  giving  a  pour 
to  the  arm,  hand,  foot,  etc.,  the  part  may  be  held  over  a  small 
tub  while  the  water  is  poured  from  a  pail  or  large  pitcher.  To 
treat  the  head  by  a  pour  the  patient  should  lie  on  a  cot  with 
head  resting  over  the  end  and  a  tub  underneath.  In  giving 
local  affusions  the  water  should  fall  a  distance  of  three  or  four 
inches  to  one  or  two  feet  according  to  the  part  treated  and 
effects  desired. 

EN  EM  ATA 

An  enema  is  an  injection  of  fluid  into  the  rectum. 

General  Directions: — 

(a)  Articles  Accessary.  An  enema  can  with  a  capacity  of 
one-half  to  two  gallons  or  a  fountain  syringe  or  combination 
bag. 


ENEMATA  47? 

Five  or  six  feet  of  rubber  tubing  with  cut-off. 

A  glass  or  hard  rubber  enema  tube. 

A  disinfectant  solution  for  the  enema  tube.  One  to  three 
per  cent  lysol  acts  both  as  a  disinfectant  and  a  soap  for  cleans- 
ing-. A  water  thermometer.  Toilet  paper. 

If  given  in  the  room,  there  should  be  in  addition  a  standard 
or  hook  for  suspending  the  enema  can,  a  bed  pan,  slop  jar  and 
several  newspapers. 

In  the  treatment  room  shelves  or  hooks  are  most  convenient 
for  holding  the  can,  they  should  be  so  arranged  that  the  eleva- 
tion of  the  enema  can  may  be  varied  from  one  to  four  feet 
above  the  patient.  (Plates  LIII,  LIV,  LV.} 

(b}  Procedure.  Fill  the  can  with  from  two  to  six  quarts  of 
water  at  the  proper  temperature  (test  with  a  thermometer). 

The  patient  should  be  warm,  especially  the  feet.  All  cloth- 
ing not  removed  should  be  loose. 

Position  of  the  patient — dorsal,  sitting,  right  Sims  or  knee  - 
chest. 

Release  the  cut-off  and  allow  the  water  to  run  until  the 
stream  is  at  the  same  temperature  as  the  water  in  the  can. 
Close  cut-off  and  lubricate  the  enema  tube,  being  careful  to 
wash  it  beforehand,  removing  the  disinfectant  solution. 

The  patient  should  insert  the  tube  unless  very  ill  or  unable 
to  do  so.  Instruct  the  patient  to  take  as  much  water  as  pos- 
sible. To  make  it  easier  to  do  this,  stop  the  flow  by  pinching 
the  tube  two  or  three  times  during  the  taking  of  the  enema. 
Close  cut-off  and  remove  the  tube.  If  possible  the  patient 
should  retain  the  water  a  few  minutes  before  discharging. 

Repeat  until  a  thorough  bowel  movement  is  secured  or  other 
desired  result  is  obtained. 

I.  PLAIN  WATER  ENEMATA 
Rectal  Injection  or  Enema — E.  or  En. 

In  the  ordinary  enema  the  desired  amount  of  fluid  is  injected, 
allowed  to  remain  a  short  time  and  then  passed.  The  pro- 
cedure is  different  from  rectal  irrigation,  in  which  there  is  a 
continuous  inflow  and  outflow  of  fluid. 


478  TECHNIQUE 

1.  Hot  Enema — H.  En.  The  temperature  of  the  hot  enema 
should  vary  from  103° — 110°  F.  according  to  the  condition  of 
the  patient  and  the  result  desired.  It  is  useful  in  relieving 
irritation,  the  pain  of  inflammation  in  the  rectum  or  prostate 
and  pain  of  hemorrhoids.  It  also  aids  in  expelling:  gas,  and 
helps  to  check  diarrhoea  by  decreasing-  rectal  tenesmus.  It  may 
be  used  as  a  preliminary  measure  in  the  treatment  of  dysmeno- 
rrhosa.  The  hot  enema  is  also  used  to  warm  and  stimulate  the 
body  in  shock.  It  markedly  relieves  the  pain  in  acute  pelvic 
and  lower  abdominal  inflammations  such  as  salpingitis  and 
appendicitis. 

2.  Warm   Enema — En.      The  ordinary  enema  for  cleansing 
purposes  should  be  given  at  a  temperature  of  95° — 100°   F. 
Where  it  has  to  be  repeated  frequently  it  is  better  to  use  tepid 
water,  i.  e.,  80° — 92°  F.,  to  avoid  as  far  as  possible  the  relaxing 
effect  of  warm  water. 

3.  Cold  Enema — C.  En.     In  giving  the  cool  or  cold  enema, 
the  temperature  of  the  water  may  vary  from  55° — 80°  F.     Up 
to  about  70°  F.  it  may  be  regarded  as  cold,  and  from  70° — 80° 
F.  as  cool.     The  cold  enema  is  a  powerful  stimulant  to  bowel 
movements  and  should  be  more  generally  used  for  this  purpose 
in  place  of  the  warm  enema.     For  this  reason  it  is  useful  in 
overcoming  the  enema  and  cathartic  habits.     If  retained  ten  or 
fifteen  minutes  or  frequently  repeated,   is  useful  in  shrinking 
hemorrhoids.     It  may  also  be  used  in  fever,  but  for  this  pur- 
pose prolonged  rectal  irrigation  is  much  more  convenient  and 
effective. 

Graduated  Enema — Grad.  E. 

The  graduated  enema  is  not  a  single  treatment,  but  a  series 
of  treatments.  It  is  used  to  overcome  the  enema  or  cathartic 
habits.  As  usually  given,  it  extends  over  a  period  of  ten  to 
twelve  days.  It  should  be  preceded  on  two  or  three  successive 
days  by  thorough  coloclysters  of  water  at  90° — 100°  F.  to  re- 
move accumulated  feces.  The  series  of  enemata  is  begun  with 
a  large  amount  of  tepid  water  and  finished  with  a  small  amount 
of  cold  water,  one  enema  being  given  daily.  In  some  cases  the 
first  two  or  three  of  the  series  may  be  omitted. 


ENEMATA  479 

1st  day  4i  pints  at  94°  F.  6th  day  2    pints  at  74°  F. 

2nd  day  4    pints  at  90°  F.  7th  day  l£  pints  at  70°  F. 

3rd  day  3s  pints  at  86°  F.  8th  day  1    pint    at  66°  F. 

4th  day  3    pints  at  82°  F.  9th  day    |  pint    at  62°  F. 

5th  day  2\  pints  at  78°  F.  10th  day    I  pint   at  58°  F. 

The  above  program  is  suggestive  only;  the  variations  in  the 
amount  and  temperature  of  the  water  should  be  made  to  suit 
the  needs  of  the  case.  The  entire  series  with  the  exception  of 
the  temperatures  above  80°  F.,  may  need  to  be  repeated.  Cold 
enemata  should  not  be  given  during  the  menses. 

Effects.  After  prolonged  use  of  cathartics,  the  muscular  part 
of  the  intestinal  wall  becomes  relaxed  and  atonic  because  of 
overstimulation.  The  response  to  drug  and  chemical  excitants 
is  worn  out  and  it  is  necessary  that  the  atony  be  overcome  by 
some  more  physiologic  means.  The  restorative  effect  of  cold 
upon  muscular  tissue  and  muscular  capacity  has  been  discussed 
in  detail  in  chapter  XIII.  Repeated  use  of  the  warm  or  hot 
enema  also  causes  relaxation  with  stretching  and  distention  of 
the  wall  of  the  rectum  and  lower  sigmoid  flexure. 

The  contact  with  the  cold  water  introduced  into  the  bowel  is 
an  effective  means  of  combating  this  atony  and  distention. 
The  gradual  reduction  in  the  temperature  makes  it  possible  to 
bring  about  a  response  even  after  the  atony  has  existed  for 
some  time.  Both  this  treatment  and  alternate  hot  and  cold 
rectal  irrigation  are  very  efficient  in  the  treatment  of  atonic 
constipation.  They  may  be  advantageously  combined  with  the 
use  of  slow  intra-rectal  and  abdominal  sinusoidal  electricty, 
abdominal  massage  and  spinal  nerve  stimulation. 

Rectal  Irrigation — Rec.  Irrig. 

In  giving  rectal  irrigation  a  special  tube  is  used  provided 
with  an  inlet  and  a  return  flow,  so  that  the  fluid  passes  into  the 
rectum  bathing  the  mucous  membrane,  and  returns  through 
the  outlet.  These  are  made  of  hard  rubber  or  metal.  The 
patient  should  be  in  the  dorsal  or  Sims  position.  The  enema 
can  should  be  eighteen  inches  to  two  feet  above  the  patient. 
The  outflow  tube  should  be  lengthened  by  attaching  to  it  a  piece 
of  rubber  tubing  so  as  to  carry  the  outflow  into  the  toilet  fixture 


480  TECHNIQUE 

or,  if  given  to  a  bed  patient,  into  a  jar  placed  at  the  side  of  the 
bed. 

1.  Hot  Rectal  Irrigation — H.  Rec.  Irrig.     When    the    water 
used  is  at  a  temperature  of  102° — 105°  or  106°  F.  the  treatment 
produces  decided  effects  in  the  relief  of  pain  and  rectal  tenes- 
mus.     It  may  also  be  used  with  great  benefit  in  cases  of  chronic 
cystitis  with  frequent  and  painful  urination. 

2.  Cold  Rectal  Irrigation — C.  Rec.  Irrig.     Cold  rectal  irriga- 
tion is  a  very  useful  antipyretic  measure.     For  this  purpose 
the  water  should  not  be  very  cold,  but  from  about  70° — 85°  F. 
and  the  treatment  continued  about  forty-five  minutes  at  a  time. 
Cold  irrigation  is  also  useful  in  stimulating  bowel  movement, 
but  for  this  purpose  it  possesses  no  advantage  over  the   cold 
enema. 

3.  Alternate  Hot  and  Cold  Rectal  Irrigation— Alt.  H.  &  C. 
Rec.   Irrig.     In  giving  alternate   hot  and   cold   irrigation  it  is 
necessary  to  use  two  .enema  cans  with  tubing  connected  by  a 
Y-tube  so  that  the  alternations  may  be  controlled.     The  hot 
should  be  allowed  to  run  from  one-half  to  two  minutes  and  the 
cold  from  fifteen  to  thirty   seconds.     From  five  to  twelve  or 
more  complete  changes  may  be   made  in  a  single  treatment. 
The  greater  the  extremes  of  temperature,  the  greater  will  be 
the  effect.     It  is  possible  to  use  a  plain  enema  tube,  injecting 
but  a  small  amount  and  allowing  the  water  to  pass  out  through 
the  enema  tube  after  each  injection. 

This  treatment  is  a  most  efficient  measure  in  the  relief  of 
chronic  inflammations  of  the  pelvic  organs,  especially  of  the 
bladder,  prostate,  posterior  urethra  and  rectum.  For  these  pur- 
poses it  should  be  given  daily  or  three  or  four  times  a  week. 
It  is  also  one  of  the  most  effective  means  of  combating  chronic 
atonic  constipation. 

Coloclyster — Ccl. 

In  a  coloclyster  the  fluid  is  introduced  into  the  colon. 

When  the  coloclyster  is  used  to  produce  thorough  cleansing 
of  the  large  bowel,  four  to  six  pints  of  water  or  saline  solution 
at  a  temperature  of  100° — 104°  F.  are  used  for  each  injection. 
An  ordinary  enema,  and  if  necessary  a  soap-suds  enema,  is 


ENEMATA  481 

first  used  to  cleanse  the  lower  bowel.  Have  the  patient  take 
the  knee-chest  or  right  Sims  position.  Use  an  ordinary  enema 
tube,  but  if  results  are  not  obtained,  it  may  be  necessary  to  use 
the  high  bowel  catheter  (colon  tube).  As  the  water  enters, 
rub  along-  the  colon  up  the  left  side,  across  the  abdomen  and 
down  on  the  right  side  so  as  to  fill  well  the  large  bowel.  As 
much  water  as  possible  should  be  injected,  but  this  should  be 
done  slowly.  Remove  the  enema  or  colon  tube  and,  as  the 
water  is  expelled,  reverse  the  movements  along  the  colon  to 
favor  complete  emptying.  It  may  be  necessary  to  repeat  the 
procedure. 

Effects.  The  coloclyster  is  used  to  produce  a  full  and  com- 
plete evacuation  of  the  bowels,  and  for  cleansing  the  large 
bowel  in  cases  where  an  ordinary  enema  does  not  produce  the 
desired  results.  .  It  is  also  used  to  remove  fecal  impaction. 
When  some  medicament  or  antiseptic  is  introduced  it  may  be 
used  to  disinfect  the  large  intestine  or  destroy  parasites,  as  the 
amoeba  coli.  (See  quinine  also  quassia  enema.) 

II.  MEDICATED  ENEMATA 

Saline  Enema — Sal.  En. 

For  whatever  purpose  the  saline  enema  is  used,  it  should  be 
preceded  by  a  thorough  cleansing  enema  unless  the  bowel  has 
already  been  cleared  of  feces. 

1.  Saline  Enema  to  be  Retained  and  Absorbed.  The  absorp- 
tion of  saline  fluid  from  the  rectum  is  useful  in  hemorrhage, 
surgical  shock  and  pelvic  and  abdominal  abscesses  after  drain- 
age has  been  instituted.  To  be  absorbed  most  rapidly,  the 
sodium  chloride  solution  should  be  isotonic  with  blood  serum 
or  slightly  hypotonic.  A  physiologic  salt  solution  is  so  called 
because  it  is  isotonic  with  blood  serum. 

Intermittent  Proctodysis .  One-half  pint  of  physiologic  salt 
solution  (0.95  per  cent)  at  a  temperature  of  100° — 105°  F.  is 
given  slowly  or  by  high  bowel  catheter.  To  make  this,  use  one 
level  teaspoonful  (4.5  grams)  of  salt  to  the  pint  of  water.  For 
a  hypotonic  solution  (more  rapid  absorption)  use  a  little  less 
salt.  After  this  has  been  absorbed,  another  one-half  pint  may 

31 


482  TECHNIQUE 

be  given.     If  this  amount  is  not  readily  retained,  use  four  or 
five  ounces  only. 

Continuous  Proctoclysis .  Murphy  Method.1  The  fluid  should 
be  administered  through  a  fountain  syringe  to  which  is  attached 
a  three-eights  inch  rubber  hose  with  a  hard  rubber  or  glass 
vaginal  douche  tip  with  multiple  openings.  This  tube  should 
be  flexed  almost  to  right  angles  three  inches  from  its  tip.  A 
straight  tube  must  not  be  used,  as  the  tip  produces  pressure  on 
the  posterior  wall  of  the  rectum  when  the  patient  is  in  the 
Fowler  position.  The  tube  is  inserted  into  the  rectum  to  the 
flexion  angle  and  secured  in  place  by  adhesive  strips,  binding 
it  to  the  side  of  the  thigh  so  that  it  can  not  come  out;  the  rubber 
tubing  is  passed  under  the  bedding  to  the  head  or  foot  of  the 
bed,  to  which  the  fountain  is  attached. 

Two  or  three  inches  from  the  fountain  syringe  interpose  a 
Y-tube  and  to  the  upper  limb  attach  a  piece  of  rubber  hose  of  the 
same  size  as  the  outlet  tube.  Fasten  the  free  end  of  this  to  the 
top  of  the  fountain  syringe  so  that  what  returns  through  it  will 
fall  into  the  container.  When  flatus  is  voided,  the  gas  passes 
more  readily  through  the  upper  tube  than  directly  into  the 
fountain  syringe.  This  reduces  the  pressure  at  such  times  and 
so  aids  in  preventing  expulsion  of  the  fluid  onto  the  linen. 

The  fountain  syringe  should  be  suspended  from  six  to  four- 
teen inches  above  the  level  of  the  buttocks  and  raised  or  lowered 
to  just  overbalance  hydrostatically  the  intra-abdominal  pres- 
sure, i.  e.,  it  must  be  just  high  enough  to  require  from  forty  to 
sixty  minutes  for  one  and  one-half  pints  to  flow  in,  the  usual 
quantity  given  every  two  hours.  The  fioiv  must  be  controlled  by 
gravity  alone,  and  never  by  a  forceps  or  constriction  on  the  tube,  so 
that  when  the  patient  endeavors  to  void  flatus  or  strain,  the 
fluid  can  rapidly  flow  back  into  the  can,  otherwise  it  will  be 
discharged  in  the  bed.  It  is  this  ease  of  flow  to  and  from  the 
bowel  that  insures  against  over-distention  and  expulsion  onto  the 
linen.  The  fountain  had  better  be  a  glass  or  graded  can,  so 
that  the  flow  can  be  estimated.  The  temperature  of  the  water 
in  the  fountain  can  be  maintained  at  100°  by  encasement  in 
hot- water  bags.  The  fountain  is  refilled  every  two  hours  with 

1     Slightly  modified  from  the  original  description  by  J.  B.  Murphy. 


EN  EM  AT  A  483 

one  and  one-half  to  two  pints  of  solution.  Instead  of  the  usual 
solution,  a  teaspoonful  of  calcium  chloride  may  be  added  to  the 
pint  of  saline  solution.  The  tube  should  not  be  removed  from 
the  rectum  after  each  emptying-  of  the  syringe  but  may  be  left 
in  place  for  two  or  three  days  if  necessary.  Since  the  introduc- 
tion of  this  method  by  Doctor  Murphy  a  great  many  appliances 
have  been  devised  for  regulating-  the  rate  of  flow  and  maintain- 
ing the  temperature  of  the  water.  Plate  LI  shows  a  seepage 
apparatus2  with  a  device  for  warming-  the  water  just  before  it 
enters  the  rectum.  The  same  thing-  may  be  accomplished  by 
placing-  an  ordinary  hot-water  bottle  over  the  rubber  tubing-  at 
its  lower  end  (.Plate  Lff.).  A  dropping  device  which  may  be 
inserted  between  the  Y-tube  and  the  irrigating  can  is  shown  in 
Plate  LII,  corner  figure.  It  is  helpful  in  regulating-  the  rate 
of  flow.  From  40  to  60  drops  per  minute  will  be  absorbed  by 
the  bowel  without  difficulty  and  more  than  this  if  much  blood 
has  been  lost.  For  the  effects  of  enteroclysis  see  chapter  IX. 

2.  Saline  Enema  to  Cause  Exosmosis,  acting  like  a  saline 
cathartic.  Used  to  produce  exosmosis,  the  enema  is  designed 
for  thorough  cleansing  of  the  mucous  membrane  and  is  of 
inestimable  value  in  chronic  mucous  colitis. 

To  produce  exosmosis,  i.  e. ,  draw  from  the  tissues  into  the 
bowel,  the  solution  must  be  hypertonic,  i.  e.,  of  greater  con- 
centration than  blood  serum.  Three  pints  of  warm  or  hot 
water  are  used,  containing  two  teaspoonfuls  of  salt  to  the  pint 
or  one-fourth  teaspoonful  of  Epsom  salts  may  be  added  to  each 
pint  of  physiologic  salt  solution.  The  enema  should  be  intro- 
duced into  the  colon  by  high  bowel  catheter  or  its  flow  into  the 
colon  aided  by  the  knee-chest  position.  Let  it  be  retained  fif- 
teen to  twenty  minutes  or  longer.  If  retained  much  over  half 
an  hour,  some  fluid  will  be  absorbed.  The  treatment  should 
always  be  preceded  by  an  ordinary  enema  to  remove  feces. 

Soap  Suds  Enema — S.  S.  En. 

Prepare  two  or  three  pints  of  warm  soap  suds  solution,  made 
by  scraping  castile  or  Ivory  soap  and  mixing  thoroughly  in 

2    Made  by  the  Boston  Surgical  Supply  Company. 


484  TECHNIQUE 

water  at  about   100°   F.     Follow  by  a  plain   enema  to  remove 
the  soap  suds. 

Effects.  The  soap  suds  enema  facilitates  evacuation  of  the 
bowels  and  should  be  used  where  the  plain  enema  fails  to  pro- 
duce results. 

Oil  Enema — Oil  En. 

In  administering:  the  oil  enema,  use  the  colon  tube  with  a 
small  enema  can  giving  one  and  one-half  to  three  or  four  ounces 
of  warmed  cotton  seed  or  other  vegetable  oil.  It  should  be 
retained  from  two  to  ten  or  twelve  hours  or  over  night.  Pass 
it  the  next  morning  and  follow  by  soap  suds  and  plain  enemata. 

Effects.  The  oil  enema  is  used  to  remove  hardened  or 
impacted  feces.  It  has  a  soothing,  relaxing  effect,  and  is  there- 
fore used  to  overcome  spastic  constipation,  as  of  chronic  lead 
poisoning.  When  given  two  or  three  days  after  an  operation 
for  hemorrhoids  it  softens  and  loosens  the  clot  so  that  it  passes 
without  causing  pain  or  starting  fresh  bleeding. 

Honey  or  Molasses  Enema 

Give  one-half  to  one  pint  of  a  warmed  solution  consisting  of 
two  parts  soap  suds  and  one  of  molasses  by  high  bowel  catheter. 
Follow  by  plain  enema.  For  less  of  the  cathartic  action  use 
four  ounces  of  honey  or  molasses  to  the  pint  of  plain  warm 
water. 

Effects.  The  honey  or  molasses  enema  has  a  purging  effect 
similar  to  that  of  the  hypertonic  saline  enema.  It  aids  in 
removing  the  mucous  casts  and  mucoua  accumulations  of 
chronic  colitis. 

Asafoetida  Enema 

To  one  pint  of  warm  water  add  four  ounces  of  an  emulsion 
of  asafoetida,  prepared  by  agitating  one-half  dram  of  asafoetida 
powder  in  four  ounces  of  water;  or  add  one  ounce  of  tincture  of 
asafcetida  to  a  pint  of  warm  water.  Give  as  an  ordinary  enema. 
It  is  used  to  expel  flatus. 

Turpentine  Enema 

To  a  pint  of  soap  suds  solution  add  ten  to  twenty  drops  of  oil 


PLATE  LI.    A  seepage  apparatus  with  device  for  warming  fluid. 


PLATE  LII.     Continuous  proctoclysis  with  hot-water  bottle  for 
warming  fluid;  corner  figure— dropping  device. 


ENEMA  TA  485 

of  turpentine.  Follow  by  a  plain  enema.  The  turpentine 
enema  is  given  in  the  same  way  and  for  the  same  purpose  as 
the  asafostida  enema.  Its  action  is  somewhat  more  vigorous. 
It  should  not  be  used  where  there  is  kidney  irritation  or 
Bright' s  disease. 

Glycerine  and  Epsom  Salts  Enema 

The  glycerine  and  Epsom  salts  enema  is  a  vigorous  purga- 
tive. It  is  used  in  cases  of  fecal  impaction  and  obstinate  con- 
stipation (obstipation). 

Just  before  using,  prepare  a  mixture  consisting  of  two  ounces 
of  magnesium  sulphate,  two  ounces  of  glycerine,  and  sufficient 
warm  water  (about  two  ounces)  to  make  it  pass  readily  through 
the  colon  tube. 

First,  cleanse  the  lower  bowel  from  feces  and  then  inject  the 
mixture  by  high  bowel  catheter,  using  gentle  pressure  with  a 
rubber  bulb  if  necessary.  Considerable  patience  and  persist- 
ence may  be  necessary  to  secure  results.  In  supposed  cases  of 
fecal  impaction,  great  care  should  be  exercised  in  diagnosis  that 
a  case  of  intussusception  is  not  treated  in  this  way.  - 

Starch  Enema 

The  warm  starch  enema  is  given  to  relieve  irritation  and 
check  diarrhoea.  Make  a  thin  paste  of  starch  in  one  or  two 
ounces  of  cold  water.  Add  hot  water  enough  to  make  from 
four  ounces  to  one  pint  of  solution.  Inject  slowly  after  giving 
a  hot  cleansing  enema.  The  sedative  effect  may  be  made  much 
greater  and  pain  relieved  by  adding  five  to  twenty  drops  of 
laudanum. 

Astringent  Enema 

An  astringent  mixture  is  'useful  in  controlling  or  checking 
diarrhoea  and  dysentery;  also  in  inflammation  of  the  rectum. 
The  bowel  should  be  cleansed  by  a  plain  enema  of  warm  or  hot 
water  before  the  astringent  is  injected.  Usually  from  four  to 
eight  ounces  is  all  that  is  desirable.  Either  of  the  following 
formulae  may  be  used: — 

(a)  A  heaping  tablespoonful  of  tannin  to  one  pint  of  water 
at  100°  F. 


486  TECHNIQUE 

(£)  An  ounce  of  glycerite  of  tannin  to  one  pint  of  water  at 
100°  F. 

Quassia  Enema 

The  quassia  enema  is  used  to  destroy  and  remove  thread  or 
pinworms  (oxyuris  vermicularis).  Prepare  an  infusion  of 
quassia  by  pouring"  over  one  and  one-half  drams  of  finely  rasped 
quassia  wood,  twenty  ounces  of  warm  water;  let  it  stand  twenty 
to  thirty  minutes  and  strain.  Use  a  plain  cleansing  enema 
first;  then  cleanse  the  colon  thoroughly  with  warm  water  con- 
taining a  teaspoonful  of  borax  to  the  pint.  Now  inject  into  the 
colon  (coloclyster)  a  half  to  a  pint  of  the  infusion  of  quassia; 
retain  as  long  as  possible.  A  1 — 10,000  bichloride  solution 
may  be  used  instead  of  the  quassia.  It  should  not  be  retained 
very  long. 

Quinine  Enema 

The  quinine  enema  is  used  for  amoebic  dysentery.  After 
thorough  cleansing  of  the  bowel  by  low  enema  and  colon 
flushing,  inject  by  high  bowel  catheter,  from  two  to  four  or 
more  pints  of  a  warmed  solution  of  quinine;  1 — 1000  or  2500. 
Large  and  frequently  repeated  coloclysters  of  cold  water  may 
be  used.  Quinine  kills  the  amrebae.  Cold  water  paralyzes 
them  for  a  time.  Position  of  patient — hips  elevated. 
•  In  very  obstinate  and  long  standing  cases  of  amoebic  dysen- 
tery, colonic  flushings  with  cold  water  or  the  quinine  solutions 
are  sometines  carried  out  by  means  of  appendicostomy. 

VAGINAL  DOUCHES  OR  IRRIGATION 

A  vaginal  douche  consists  in  the  flushing  or  irrigating  of 
the  vaginal  cavity  by  a  fluid. 

General  Directions: — 

.(«)  Articles  Necessary  in  the  Treatment  Room.  Douche  bench, 
fountain  syringe  or  douche  can  with  a  capacity  of  one  or  two 
gallons,  five  or  six  feet  of  rubber  tubing,  douche  tube  of  glass 
or  hard  rubber,  lubricant,  disinfectant,  sheets  and  napkins. 
Additional  need  in  private  room :  Standard  or  hooks  for  douche 
can,  a  douche  pan,  slop  jar,  and  rubber  sheeting  or  papers. 


VAGINAL  IRRIGATION  487 

(£)  Procedure.  Preparation  of  the  douche.  Fill  the  can  with 
from  two  to  four  quarts  of  water  at  the  prescribed  temperature 
and  place  it  from  three  to  four  feet  above  the  patient.  Always 
use  a  thermometer  in  preparing  vaginal  douches. 

Preparation  of  patient.  If  the  clothing-  is  not  removed,  pro- 
tect thoroughly.  Always  cover  the  patient  with  a  sheet.  Lub- 
ricate the  tube  with  vaseline  or  soap.  Release  the  cut-off  and 
allow  the  water  to  run  a  few  seconds.  Instruct  the  patient  to 
insert  the  tube  unless  helpless. 

Position  of  patient.  Dorsal  position  with  hips  raised  and 
thighs  and  legs  flexed. 

I.  PLAIN  VAGINAL  IRRIGATION 

Vaginal  Irrigation  for  Ordinary  Use 

1.  Hot  Vaginal  Irrigation — V.  I.     This  is  used  for  cleansing 
purposes.     Two  to  four  quarts  of  water  are  employed  at  a  tem- 
perature of  105°— 115°  F.     Finish  with  a  pint  of  water  at  70°  F. 

In  the  treatment  of  pelvic  inflammations,  the  hot  vaginal 
douche  is  usually  given  as  a  preliminary  to  the  use  of  the  sitz 
bath,  hot  half-bath  or  the  hip  and  leg  pack. 

2.  Very  Hot  Vaginal  Irrigation — H.  V.  I.     The  very  hot  vag- 
inal irrigation  is  designed   for  the  relief  of  pain  or  to  check 
hemorrhage.     Two  to  four  quarts  of  water  are  used  at  a  tem- 
perature of  110°— 125°  F. 

3.  Alternate  Hot  and  Cold  Vaginal  Irrigation— H.  &  C.  V.  I. 
Alternate  hot  and  cold  vaginal  irrigation  is  given  for  tonic  and 
stimulating  effects.     It  is  also  used  in  chronic  pelvic  inflamma- 
tions.    Use  two  cans  with  a  Y-tube  connection.     Put  four  quarts 
of  water  in  one  can^at  a  temperature  of  110° — 120°  F.,  and  two 
quarts  of  water  in  the  other  at  a  temperature  of  70°  F. 

Give  the  hot  fifteen  to  thirty  seconds  and  the  cold  five  to  ten 
seconds.  Continue  the  alternations  for  five  to  ten  minutes, 
beginning  with  hot  and  finishing  with  cold. 

Vaginal  Irrigation  During  Pregnancy 

During  pregnancy  certain  precautions  must  be  observed. 
The  pressure  of  the  water  must  not  be  too  great,  i.  e.,  the 


488  TECHNIQUE 

douche  can  must  not  be  placed  too  high.  Very  cold  water  or 
extremely  hot  water  should  not  be  used.  It  is  positively  nec- 
essary that  the  opening's  in  the  bulb  of  the  douche  tube  be  lat- 
eral and  not  directly  on  the  end.  During  pregnancy  vaginal 
irrigation  is  given  chiefly  for  cleansing,  for  the  treatment  of 
leucorrhoea  and  for  the  relief  of  irritation.  Use  two  to  four 
quarts  of  water  at  a  temperature  of  98°: — 105°  F.  Hang  the 
douche  can  twelve  to  eighteen  inches  above  the  hips. 

II.  DISINFECTANT  AND  MEDICATED  DOUCHES 
Soap  Suds  Vaginal  Irrigation — S.  S.  V.  I. 

Use  two  quarts  of  soap  suds  solution  prepared  from  laundry 
soap  or  green  soap  solution  at  a  temperature  of  105° — 110°  F. 
Wrap  the  tube  in  cheesecloth  and  swab  the  vagina  carefully, 
but  thoroughly,  while  the  water  is  flowing.  Follow  by  plain 
vaginal  irrigation,  then  give  a  permanganate  or  bichloride 
douche. 

The  soap  suds  vaginal  irrigation  is  used  to  prepare  patients 
for  surgical  operations  or  for  special  cleansing  and  disinfectant 
purposes. 

Permanganate  of  Potassium  Vaginal  Irrigation — P.  V.  I. 

To  one  quart  of  water  add  two  drams  (two  teaspoonfuls)  of 
a  saturated  solution  of  potassium  permanganate  (1 — 2000). 
Temperature,  110° — 120°  F.  Precede  by  a  plain  vaginal  irriga- 
tion. Oxalic  acid  (sat.  sol.)  will  remove  the  stain. 

The  permanganate  douche  is  used  as  a  deoderant  and  disin- 
fectant in  the  treatment  of  vaginal  inflammations,  leucorrhoea, 
etc.,  also  as  a  disinfectant  preparatory  to  operation. 

Bichloride  of  Mercury  Vaginal  Irrigation — Bichlor.  V.  I. 

.  Use  one  dram  (a  teaspoonful)  of  a  saturated  solution  of 
bichloride  of  mercury  to  one  or  two  quarts  of  water  (l — 4000 
or  8000).  Temperature,  110°— 115°  F.  Always  precede  by 
plain  vaginal  irrigation,  so  as  to  remove  all  mucus  and  other 
secretions.  If  this  is  not  done  the  disinfectant  properties  of  the 
bichloride  are  lessened  by  its  combination  with  albuminous 
substances. 


VAGINAL  IRRIGATION  489 

Carbolic  Acid  Vaginal  Irrigation — Carb.  V.  I. 

Use  one-half  ounce  of  a  five  per  cent  solution  to  one  quart  of 
water.  Temperature,  110° — 115°  F.  Be  sure  that  the  solu- 
tion is  thoroughly  mixed  with  the  water,  otherwise  a  carbolic 
acid  burn  may  result.  Always  have  alcohol  at  hand  in  giving 
this  douche. 

Creolin  or  Lysol  Vaginal  Irrigation 

Use  a  one  or  two  per.cent  solution  of  either  lysol  or  creolin  in 
water  at  a  temperature  of  110° — 120°  F.  These  disinfectants 
are  much  used  after  confinement  where  puerperal  infection  has 
occurred  or  in  case  of  a  suspicious  odor  to  the  lochia. 

Acetic  Acid  or  Vinegar  Vaginal  Irrigation 

The  acetic  acid  douche  is  used  to  check  hemorrhage.  Use 
one  quart  of  boiled  vinegar  to  one  quart  of  water  or  one  ounce 
of  glacial  acetic  acid  to  one  quart  of  water.  Temperature, 
115°— 120°  F. 

Alum  Vaginal  Irrigation — Alum  V.  I. 

The  alum  douche  is  also  used  to  check  hemorrhage  or  pro- 
longed menses.  Add  one  pint  of  a  saturate  solution  of  alum  to 
one  pint  of  water.  In  extreme  cases  the  sat.  sol.  may  be  used. 
Temperature,  115° — 120°  F.  Precede  by  plain  hot  vaginal 
irrigation. 


490  TECHNIQUE 

PRESCRIPTION  WRITING  AND 
TREATMENT  COMBINATIONS 

NEITHER  the  art  of  prescription  writing:  nor  a  working 
knowledge  of  therapeutic  effects  can  be  obtained  without 
preliminary  training:  and  experience  in  the  technique  of  hydro- 
therapy.  Treatment  combinations  which  are  agreeable  and 
pleasing  to  the  patient  are  perfectly  compatible  with  scientific 
arrangement;  in  fact,  combinations  which  are  disagreeable  are 
rarely  efficient  and  need  alterations  or  additions  in  order  to 
become  so.  On  an  average,  treatments  given  to  ambulatory 
patients  in  the  treatment  rooms  should  require  about  forty-five 
or  fifty  minutes.  Except  with  certain  applications,  a  longer 
time  is  usually  detrimental  rather  than  beneficial.  With  bed 
patients,  in  cases  of  nephritis,  pleurisy,  pneumonia  and  other 
inflammatory  diseases,  organic  nervous  diseases,  etc.,  each 
case  should  be  a  law  unto  itself  as  to  the  duration  of  treatment 
and  the  frequency  with  which  applications  are  to  be  repeated. 
A  mistake  very  commonly  made  in  prescribing  hydrotherapy 
is  the  giving  of  a  different  treatment  each  day.  If  a  medicine 
were  to  be  taken,  no  one  would  think  of  altering  it  for  each 
day.  For  the  same  reason  hydrotherapeutic  treatment  should 
vary  only  as  the  patient's  condition  varies,  as  improvement 
occurs,  or  some  special  result  is  to  be  obtained. 

In  the  proper  combining  of  procedures  lies  the  philosophy  of 
securing  a  predetermined  physiologic  effect,  and  hence  a  de- 
sired therapeutic  result  in  a  given  case.  It  requires  a  far  more 
intimate  knowledge  of  normal  and  abnormal  physiology  in  order 
to  prescribe  hydrotherapy  than  it  does  to  prescribe  medicinal 
substances  for  internal  medication.  The  securing  of  results  in 
difficult  cases  requires  also  a  much  closer  personal  supervision. 

In  making  treatment  combinations  it  should  be  a  general 
rule  to  combine  for  simultaneous  application  as  many  of  the  indi- 
vidual procedures  to  be  given  as  possible  and  secure  the  desired 
result.  For  example, — in  giving  a  hot  foot  bath,  hot  and  cold 
to  the  spine,  and  a  cold  mitten  friction,  the  patient  may  take 
the  hot  foot  bath  and  the  hot  and  cold  to  the  spine  simultane- 


PRESCRIPTION  WRITING  491 

ously,  if  they  are  able  to  sit  up.  The  cold  friction  should  be 
begun  with  the  arms  when  the  last  fomentation  has  been 
applied  to  the  spine.  After  treating:  the  arms,  the  fomentation 
is  removed  from  the  spine  and  the  cold  friction  given  to  the 
back.  The  feet  are  removed  from  the  hot  water  only  when  the 
attendant  reaches  the  legs  and  feet  with  the  cold  friction.  This 
combination  is  more  pleasing:  to  the  patient,  it  secures  better 
results,  and  requires  less  time  than  where  each  procedure  is 
given  separately,  one  following  the  other.  Such  a  combination 
is  much  easier  to  give  in  case  of  a  prescription  for  a  hot  foot 
bath,  fomentations  to  the  abdomen  and  a  cold  mitten  friction. 
The  patient  may  recline  for  all  of  the  treatment.  The  hot  foot 
bath  is  started,  then  the  fomentations  to  the  abdomen,  and 
when  the  third  one  has  been  placed,  begin  the  cold  friction 
with  the  arms,  removing  the  fomentation  to  the  abdomen  when 
ready  to  treat  the  anterior  part  of  the  trunk.  The  feet  are 
next  removed  from  the  hot  water  and  the  friction  given  to  the 
legs  and  the  feet.  Lastly  the  patient  turns  and  the  back  is 
treated.  Given  in  this  way,  the  reaction  from  the  cold  friction 
is  more  prompt  in  appearing  and  more  complete,  because  the 
hot  applications  give  a  sensation  of  heat.  The  use  of  the  hot 
foot  bath,  the  ice  bag  to  the  heart,  the  cold  compress  to  the 
head  and  neck  simultaneously  with  other  applications  act  pre- 
cisely like  adjuvant  and  corrigens  agents  in  medicinal  therapy. 

Also  as  a  general  rule,  treatments  to  be  given  on  a  treatment 
table  should  precede  treatments  to  be  given  in  the  wet  rooms.  For 
example, — fomentations  over  the  liver,  a  salt  glow,  and  a  hot 
and  cold  percussion  douche  to  the  spine  and  legs.  Coming  in 
any  other  order  than  that  given  would  entail  repeated  drying 
of  the  skin  surface,  and  so  lessen  the  pleasing  effect  of  the 
treatment. 

This  same  prescription  serves  to  illustrate  the  principle  that 
the  milder  procedures  should  be  given  first,  those  which  produce  the 
greatest  reaction  last.  The  fomentation  is  a  mild  application, 
the  salt  glow  is  more  vigorous ,  and  the  hot  and  cold  douche  to 
the  spine  and  legs  the  most  stimulating  of  the  three.  The  first 
two  prepare  the  patient  for  the  last  application.  Given  in  any 
other  order,  the  treatment  would  resemble  an  anticlimax. 


492  TECHNIQUE 

Somewhat  the  same  principle  is  involved  in  the  rule  that  /;/ 
a  single  treatment  there  should  not  be  given  fco  generalized  appli- 
cations of  cold,  both  of  which  are  designed  to  produce  a  tonic  reaction . 
For  example, — a  cold  mitten  friction  and  a  wet  sheet  rub  should 
not  be  given  in  the  same  treatment,  nor  a  cold  towel  rub  and  a 
hot  and  cold  douche  to  the  spine  and  legs.  Such  combinations 
draw  too  heavily  upon  the  patient's  reactive  powers. 

Such  sweating-  treatments  as  the  electric  light  bath,  Russian 
or  Turkish  baths  should  be  immediately  followed  by  a  shower, 
spray  or  pail  pour  so  as  to  wash  off  the  skin  surface,  cool  the 
body  quickly  and  produce  such  a  reaction  that  the  patient  will 
not  take  cold. 

In  the  application  of  therapeutic  agents  the  physician  should, 
incline  more  and  more  to  specific  therapy.  But  each  case  should 
be  studied  with  a  view  to  individualizing  the  treatment  so  as  to 
treat  the  patient,  not  merely  his  disease. 

The  following  prescriptions  will  serve  to  illustrate  the  rules 
given  above  and  in  a  general  way  be  suggestive  of  the  proper 
treatment  in  the  conditions  named. 

ONSET  OF  GRIPPE 

H.  Lg.  B.,  Fo.  Sp.,  C.  C.  Hd.  &  Nk.,  drink  hot  lemonade  (to 
free  perspiration),  Grad.  Sh.  115°— 90°,  5  Min. 

CHRONIC  COLD  IN  HEAD 

H.  Ft.  B.  or  H.  Lg.  Pk.,  Alt.  H.  &  C.  Hd,  30  Min.;  C.  C. 
Hd.  &  Nk.,  H.  &  C.  Perc.  D.  Ft.  (6  changes). 

DILATED  COLON  AND  ATONIC  CONSTIPATION 

Fo.  Abd.,  C.  rub  Z.  80°,  5  Min.;  Alt.  H.  &  C.  Fan.  D.  Abd., 
Alt.  H.  &  C.  Perc.  D.  to  lower  D.  and  L.  Sp.,  S.  Sinu.— stabile 
electrode  to  lower  D.  and  L.  Sp.,  labile  hand  Spg.  to  Abd. 
over  colon. 

ACUTE  SALPINGITIS  (LEFT) 

H.  Hp.  &  Lg.  Pk.,  ice  bag  above  left  groin,  20—30  Min., 
Cmf.  Leave  ice  "bag  over  tube  or  apply  heating  compress. 

ACUTE  PLEURISY  (RIGHT) 
H.  Ft.  B.,  Fo.   Rt.   Ch.    (until  pain  is  relieved,   4  or  5  if 


PRESCRIPTION  WRITING  49S 

needed),    Cmf.    (to  all  but  Rt.    Ch.),   apply  dry  Ch.    Pk.  or 
warm  flannel  vest. 

CHRONIC  PLEURISY  (RIGHT) 

H.  Ft.  B.,  Fo.  Rt.  Ch.,  Alt.  H.  &  C.  Spr.  D.  Rt.  Ch.,  Perc. 
D.  to  Ft. 

ACUTE  UREMIA 

Hypotonic  Sal.  En.  1  Pt.,  H.  B.  P.  reinforced  with  hot- 
water  bottles,  ice  Bg.  over  Ht.  and  lower  sternum  about  30 
Min. ,  tepid  Spgf.  or  light  Cmf.  Place  between  warm  blankets. 

ACUTE  MASTOIDITIS 

H.  Lg.  B.,  ice  bags  over  carotids,  large  Fo.  over  mastoid, 
30  Min.;  Cmf.  to  Lgs. 

ACUTE  PHARYNGITIS 

H.  Ft.  B.,  Fo.  Th.  and  upper  Ch.,  C.  C.  Hd.,  Cmf.,  Heat- 
ing C.  Th. 

BRONCHOPNEUMONIA  IN  FIVE-YEAR  OLD  CHILD 

Warm  tub  bath,    102°,  6  Min.,    Heat.  W.  S.  P.,   leave  child 
_  alone  if  it  sleeps,  if  not  remove  in  1  Hr.  by  tepid  Spg. 

ACUTE  GONORRHCEAL  ARTHRITIS  OF  KNEE 
Ice  Pk.  knee  1  Hr.,  Alt.  H.  &  C.  Spr.  D.  knee. 

CHRONIC  SYPHILITIC  ARTHRITIS  OF  KNEES 
Fo.  knees,  Alt.  H.  &  C.  Spr.  D.  knees  (6  changes). 

ACUTE  CHOLECYSTITIS 

H.  Ft.  B.,  Fo.  liver  and  upper  Abd.,  Cmf.  (avoid  Abd.), 
M.  A.  B. 

Mucous  COLITIS 

Hypertonic  Sal.  En.  (knee  Ch.  position)  (pass  in  20  Min.), 
Fo.  Abd.,  Cmf. 

PROSTATIC  HYPERTROPHY  AND  CHRONIC  CYSTITIS 
H.  Ft.  B.,  Fo.  lower  Abd.,  Rev.  Z. 


494  TECHNIQUE 

OLD  GLEET 
Alt.  H.  &  C.  Rec.  Irrig.,  Rev.  Z.,  Alt.  H.  &  C.  perineal  D. 

SPLANCHNIC  NEURASTHENIA 

H.  Ft.  B.,  C.  coil  Abd.f  C.  C.  Hd.,  30  Min.;  Cmf. 
PERSISTENT  VOMITING 

Hot  &  Heat.  Tr.  Pk.  (apply  10  Min.  before  meal,  leave  on  1 
to  2  Hrs.,  Cmf. 

HYPERCHLORHYDRIA 

Two  glasses  hot  water  15  Min.  before  meal;  ice  Bg.  over  St. 
after  meal  20  Min. 

CHRONIC  MITRAL  INSUFFICIENCY 
(with  cardiac  liver  and  edema  of  legs) 

Ice  Bg.  Ht.,  Rev.  C.  liver,  Alt.  H.  &  C.  Lg.  B.  (6  changes), 
Cmf.,  Cf.  Lgs. 

ACUTE  ENDOCARDITIS  WITH  DILATED  HEART 

Ice  Bg.  over  Ht.  30  Min.  every  Hr.,  H.  Lg.  Pk.  (up  to 
knees  only),  ice  Bg.  Ht.,  Cmf.  (give  twice  daily). 

INSOMNIA 
Fo.  Sp.,  O2  B.  (5  P.  M.). 

VARICOSE  ULCER 

Alt.  H.  &  C.  Lg.  B.,  30  Min.  daily  (increase  usual  duration 
of  cold  to  equal  with,  then  greater  than,  the  hot),  Alt.  H.  &  C. 
Spr.  D.  Lgs. 

LUMBAGO 

Fo.  lower  Bk.,  H.  &  C.  Perc.  D.  to  same,  short  static  spark 
to  painful  muscles. 

TROPHIC  ULCER  OR  DIABETIC  GANGRENE  OF  FOOT 
ALT.  H.  &  C.  Ft.  B.,  30  Min.  twice  daily. 

HEMORRHOIDS 

Prolonged  C.  Shal.  Z.,  90°— 70°,  10  to  15  Min.;  Alt.  H.  & 
C.  perineal  D. 


APPARATUS  495 

HYDROTHERAPEUTIC  APPARATUS 
AND  TREATMENT  ROOMS 

THE  plan  and  equipment  for  hydrotherapeutic  treatment 
rooms  must  of  necessity  vary  with  the  institution  in  which 
they  are  to  be  used  and  the  class  of  cases  to  be  treated.  We 
shall  have  most  to  say  of  treatment  rooms  for  general  use  in 
institutions  that  accept  all  classes  of  medical  and  surgical  cases 
and  the  ward  equipment  in  general  hospitals. 

In  hospitals  for  the  insane  the  equipment  need  not  be  exten- 
sive in  variety,  but  many  pieces  of  the  same  kind  are  necessary. 
Especially  should  the  receiving  ward  appliances  for  the  treat- 
ment of  mania  be  numerous  enough  to  treat  many  cases  simul- 
taneously. The  tubs  for  the  continuous  flowing  bath  together 
with  their  mixers  and  controllers  and  the  pack  tables  with  their 
outfit  make  up  the  chief  equipment  required.  These  should  be 
separate  from  other  appliances  as  perfect  quiet  is  essential. 
For  general  use,  another  room  or  rooms  should  be  fitted  with  a 
spray  and  douche  controller  and  its  spray,  shower,  douches, 
bidet  or  other  attachments.  Sitz  tubs  and  flowing  bath  tubs 
are  best  not  connected  with  the  spray  and  douche  controller, 
but  should  be  separately  controlled.  In  the  same  room  or  an 
adjoining  room  should  be  the  electric  light  bath  cabinet  and 
the  hot  air  and  steam  cabinets  for  the  Turkish  and  Russian 
baths.  Here  and  there,  convenient  to  the  general  wards  of  the 
institution,  should  be  arranged  pack  tables  and  tubs  for  the 
flowing  bath,  also  a  fomentation  tank  and  an  enema  and  vaginal 
douche  bench. 

General  Treatment  Rooms 

In  sanataria  and  office  treatment  rooms  the  plan  and  equip- 
ment should  be  ample  for  administering  all  forms  of  hydro- 
therapy.  Convenience,  of  use  and  economy  of  operation  are 
most  essential.  In  any  but  very  small  institutions  separate 
rooms  should  be  provided  for  men  and  women  so  that  they  may 
be  used  at  any  hour  of  the  day  or  night.  Considerably  more 
than  fifty  per  cent  of  all  cases  are  best  treated  in  the  forenoon 


496  TECHNIQUE 

hence  the  disadvantage  of  common  rooms  in  which  separate 
hour  must  be  arranged . 

As  far  as  possible  treatment  rooms  should  be  on  the  ground 
floor  because  of  the  great  expense  not  to  say  almost  impossi- 
bility of  rendering  floors  wholly  non-leaking.  However  this 
may  be  accomplished  by  the  use  of  sheet  lead  as  a  base  for 
cement  or  the  use  of  the  more  expensive  floorings  of  woodstone, 
plastone,  etc.  Glazed  tile  walls  and  unglazed  tile  flooring  are 
very  serviceable  but  are  not  proof  against  cracking.  Marble  is 
excellent  for  the  walls  of  spray  and  douche  stalls  but  solid  con- 
crete walls  are  equally  durable. 

Every  treatment  room  should  be  divided  into  three  separate 
sets  of  apartments  by  partitions  from  floor  to  ceiling  so  that  a 
different  temperature  may  be  maintained  in  each.  This  is  an 
essential  which  should  not  be  overlooked  or  disregarded  as 
otherwise  great  annoyance,  inconvenience  and  even  danger 
may  result  to  patients  from  overheating  and  taking  cold.  The 
first  room  should  contain  the  matron's,  treatment  director's  or 
head  nurse's  office,  the  linen  supplies,  waiting  room,  and  the 
patient's  dressing  rooms.  The  temperature  of  this  room  should 
be  about  68°  F.  and  well  ventilated.  The  next  room  should 
contain  the  individual  treatment  rooms,  each  provided  with  a 
treatment  table,  a  stool  and  hooks  or  bars  for  towels,  sheets. 
etc.  The  temperature  of  this  room  should  be  about  80°  F.  or 
so  that  it  is  comfortable  for  patients  while  taking  packs,  fomen- 
tations, cold  frictions,  massage,  etc. 

The  third  room  which  we  may  appropriately  speak  of  as  the 
wet  room  is  to  be  maintained  at  a  higher  temperature  and  con- 
tains at  one  end  sitz  tubs,  leg  tubs,  the  full  length  bath  tubs, 
salt  glow  room,  etc.  If  the  temperature  of  the  wet  rooms  is  too 
high  these  appliances  should  be  separated  from  it.  At  the 
other  end  of  the  wet  room  should  be  installed  the  spray  and 
douche  controller  and  its  attachments  and  all  the  appliances  for 
hot  baths  such  as  the  electric  light,  Turkish  and  Russian  cabi- 
nets or  rooms.  If  thought  best  these  latter  may  be  placed  in  a 
room  immediately  adjoining  the  spray  and  douche  apparatus 
but  in  any  case  the  patient  should  have  to  go  only  a  few  steps 
from  any  hot  bath  to  the  spray,  so  that  there  will  be  no  oppor- 


APPARATUS 


49? 


tunity  for  chilling.  A  drying  room  opening  from  the  spray 
room  is  also  a  distinct  advantage.  The  fomentation  tank  and 
steam  boxes  should  be  convenient  to  the  treatment  tables  so  as 
to  save  unnecessary  steps.  They  should  have  hoods  over  them 
for  carrying  off  the  steam.  If  these  are  not  provided  the 
steam  boxes  should  be  installed  in  the  wet  rooms. 


Fig.  61.    Plan  of  fomentation  tank. 

The  walls,  ceiling,  and  all  partitions  in  the  wet  rooms  should 
be  of  some  impervious  material  upon  which  water  and  steam 
will  have  no  effect.  Cement  is  best  and  cheapest  for  floors. 
Cement  on  metal  lath  for  partitions  and  frosted  or  figured  glass 
above  six  feet  is  most  serviceable  and  durable.  Marble  or  tile 
may  be  used  but  is  more  expensive  and  no  more  durable. 
Figured  pressed  metal  may  be  used  for  ceiling  if  the  joints  are 
perfect  and  the  whole  painted  and  enameled. 

32 


498 


TECHNIQUE 


Treatment  Appliances 

The  Fomentation  Tank.  This  should  be  an  enameled  iron 
tank  of  oblong-  deep  form  preferably  with  an  end  outlet.  If  it 
is  to  set  against  the  wall  it  may  be  filled  by  an  ordinary  wall 
faucet.  Where  many  nurses  are  working-  at  the  same  time  it 
is  best  to  have  the  fomentation  tank  set  away  from  the  wall  so 
that  two  wringers  may  be  attached  (Plate  XXIII).  In  this 
case  the  inlet  should  be  from  below  just  above  the  trap  for  the 
waste  (Fig.  61}.  The  waste  should  be  controlled  by  a  valve, 
never  by  the  ordinary  plug-  in  the  bottom  of  the  tank.  The 


Fig.  62      Steam  coil  for  heating 
fomentation  water — obverse. 


Fig.  63.    Steam  coil  for  heating 
fomentation  water— reverse. 


water  should  be  heated  by  a  long'  copper  coil  (twelve  or  fifteen 
feet  of  eighth-inch  pipe)  through  which  live  steam  passes. 
The  supply  pipe  to  this  coil  also  enters  from  below  and  is  con- 
trolled by  a  valve.  The  entering-  steam  should  go  to  the  center 
of  the  coil  and  the  steam  exit  be  by  a  perforated  disk  also  at 
the  center  of  the  coil  (Figs.  62  and  63).  This  arrangement  pre- 
vents "bumping"  and  the  operation  of  the  coil  is  absolutely 
noiseless  even  in  cold  water.  The  wringers  should  be  extra 
long  and  may  be  made  by  replacing-  the  rubber-covered  rollers 
of  an  ordinary  steel  spring  wringer  by  rollers  made  of  two- 


APPARATUS 


499 


inch  galvanized  iron  pipe.  When  bolted  on  at  the  end  of  the 
tank  and  ready  for  use,  the  rollers  should  be  covered  with 
heavy  unbleached  muslin  by  rolling:  the  cloth  on  so  as  to  make 
the  covering  about  three  layers  thick. 

Steam  Boxes.  When  heated  directly  by  live  steam ,  fomenta- 
tions and  packs  are  hotter  and  the  heat  is  retained  longer  than 
when  wrung  from  boiling  water.  For  this  purpose  steam 
boxes  may  be  provided  or  several  cloths  steamed  in  a  papier 


Fig.  64.     Plan  of  steam  box. 

mache  pail.  In  the  former  case  the  boxes  may  be  arranged  as 
shown  in  Plates  XXIV  and  XXV.  The  steam  inlet  should  be 
by  a  perforated  pipe  below  a  perforated  false  bottom  {Fig.  64) . 
The  box  should  have  an  outlet  for  the  condensed  steam.  One 
end  of  the  box  should  have  a  long  shallow  notch  in  it  through 
which  the  end  of  the  folded  fomentation  cloth  or  pack  blanket 
may  project.  The  cover  should  have  turned  down  edges  one 
and  one-half  or  two  inches  wide  which  should  fit  over  the  walls 
of  the  steam  box.  The  steam  should  be  turned  off  when  the 
box  is  opened. 


500  TECHNIQUE 

Leg  Tubs.  These  should  be  made  of  heavy  galvanized  iron. 
They  should  be  sixteen  inches  in  diameter  and  twenty-four 
inches  high.  The  bottom  should  be  set  up  about  two  inches 
from  the  base.  It  should  have  an  extra  ring  of  galvanized  iron 
soldered  underneath  to  help  support  the  weight  of  the  water. 
The  outlet  may  be  by  a  large  size  molasses  faucet  (.Fig.  65.}  or 
a  flume  gate  of  galvanized  iron  (Fig.  66.  and  Plate  IX.} .  Two 
such  tubs  are  necessary. 

Foot  Tubs.  Foot  tubs  should  be  made  of  medium  weight 
galvanized  iron.  An  elliptical  shape  is  best  with  rigid  handles 
at  the  ends.  The  base  should  be  about  eleven  inches  in  cross 
diameter  and  fifteen  inches  long.  The  sides  should  flare  to  a 
cross  diameter  of  about  fifteen  inches  and  a  long  diameter  of 


Fig.  65.    Molasses  faucet  Fig.  66.    Campbell  flume  gate 

outlet  for  leg  tub.  outlet  for  leg  tub. 

nineteen  or  twenty  inches.  The  tub  should  be  nine  inches 
deep.  Two  extra  sets  of  hot  and  cold  water  faucets  should  be 
provided  at  some  convenient  place  for  the  filling  of  foot  tubs, 
pails,  basins,  etc.,  so  that  it  will  not  be  necessary  to  go  to  bath 
tubs  or  the  douche  controller  for  this  purpose. 

Bath  Tubs.  Bath  tubs  should  be  six  feet  long  for  men  and 
five  and  a  half  or  six  feet  for  women.  They  should  be  set  up 
from  the  floor  four  to  six  inches.  If  this  extra  base  is  of  well 
painted  wood  it  will  serve  also  for  the  insulation  necessary  in 
giving  electro-thermal  baths.  For  the  latter  purpose  the  mix- 
ing faucet  supply  should  be  attached  to  the  wall  at  the  foot  of 
the  tub  and  have  no  connection  with  the  tub  itself  (Plate 
XXXIX).  The  outlet  should  also  be  disconnected  from  the 
plumbing,  the  waste  water  running  into  a  cement  gutter.  The 
overflow  should  be  carried  up  under  the  roll  of  the  tub  and 


APPARATUS  501 

curve  down  so  as  to  discharge  into  the  same  gutter.  This 
allows  of  filling  the  tub  to  nearly  its  full  capacity,  as  is  desir- 
able in  giving  the  neutral  bath  and  the  oxygen  bath.  A  drill 
hole  at  the  highest  point  of  this  overflow  will  prevent  siphon- 
age.  Where  the  Nauheim  bath  is  given  frequently,  a  wooden, 
or  better  a  glass  tub,  should  be  provided  as  the  acid  soon  des- 
troys the  metal  fittings. 

Sitz  Tubs.  These  should  be  of  the  deepest  pattern  that  can 
be  secured.  They  should  have  a  broad  roll  under  the  knees 
and  a  high  back.  If  the  overflow  does  not  permit  of  filling  the 
tub  nearly  to  the  knee  roll  it  should  be  altered  so  that  this  may 
be  done,  as  many  abdominal  as  well  as  pelvic  conditions  are 
amenable  to  a  very  deep  sitz'  bath.  For  giving  the  alternate 
hot  and  cold  sitz,  two  such  tubs  should  be  installed  side  by  side. 

Electric  Light  Cabinets.  For  the  upright  cabinet  a  hex- 
agonal shape  brings  the  lights  nearest  to  the  patient  and  the 
mirrors  concentrate  the  light  upon  the  patient  more  perfectly 
(Plate  XLVI.).  Thirty-six  incandescent  bulbs  arranged  in 
six  upright  rows  of  six  each  at  the  angles  of  the  cabinet  are 
sufficient  if  the  mirrors  are  perfect  and  of  large  size.  Some 
manufacturers  use  fifty  lights.  Each  row  is  controlled  by  a 
separate  switch  or  all  may  be  turned  on  from  one  switch.  The 
mirrors  should  cover  the  entire  space  between  the  columns  of 
lights.  A  small  bunch  of  lights  may  be  arranged  under  a 
heavy  glass  at  the  feet  or  they  may  be  more  effectively  warmed 
by  a  hot  foot  bath.  For  the  horizontal  cabinet,  some  manufac- 
turers use  a  cylindrical  cabinet  with  a  sliding  table  similar  to  the 
cabinet  used  for  the  superheated  air  bath  (Plate  XLIII.\.  We 
prefer  a  cabinet  made  of  an  extra  wide  treatment  table  with 
cane  top  under  which  about  three  bunches  of  lights  are  arranged 
so  that  these  may  be  turned  on  for  the  feet  and  legs  only  or  the 
hips  or  spine  only;  and  over  which  is  fastened  by  hinges  at 
one  side  a  large  semicylinder  likewise  fitted  with  lights  arranged 
in  circular  rows  so  that  one  or  more  of  these  may  be  turned  on 
as  desired  (Plate  XLVIL}.  This  cylinder  is  shorter  than  the 
table  so  that  the  head  may  be  outside.  The  opening  for  the 
neck  in  either  the  upright  or  the  horizontal  cabinet  should  not 


502  TECHNIQUE 

be  of  rigid  material  as  it  is  too  suggestive  of  confinement  in 
nervous  patients  and  is  undesirable  in  any  case. 

Russian  and  Turkish  Bath  Rooms.  The  construction  of 
these  has  been  quite  fully  considered  under  technique.  We 
prefer  a  cabinet  in  the  form  of  a  room  so  that  the  patient  may 
recline  on  a  marble  slab  with  the  head  outside  a  sliding-  win- 
dow. There  is  less  danger  of  fainting  with  the  patient  in  this 
position  and  the  same  may  be  said  of  the  horizontal  electric 
light  cabinet.  Besides  this  the  marble  slab  may  also  be  used 
for  shampoo  purposes  and  a  shower  for  cooling  off  the  patient 
be  installed  in  the  same  room  (Plates  XL  and  XL/).  Where 
steam  coils  are  arranged  under  the  marble  slab  a  thick  layer  of 
some  non-conductor  of  heat  should  be  placed  over  these  coils  so 
that  the  marble  will  not  become  overheated. 

Dryer.  A  dryer  for  fomentation  cloths,  sheets  and  towels  is 
a  necessity  in  every  treatment  room.  This  may  be  made  after 
the  plan  of  a  laundry  dryer  being  heated  by  steam  coils.  It  is 
well  to  have  several  trays  or  carts  that  pull  out  separately. 
These  may  conveniently  run  on  sliding  door  hangers  or  a  simi- 
lar device.  Each  one  should  be  seven  or  eight  inches  wide  by 
five  or  six  feet  high  and  consist  of  five  or  six  half-inch  gas  pipe 
bars  six  feet  long.  The  number  of  such  pulls  required  will 
depend  upon  the  number  of  patients  to  be  treated.  A  dryer  of 
six  takes  up  but  little  space  and  is  ample  for  twenty-five  to 
forty  patients  a  day.  It  is  well  for  sake  of  convenience  to 
install  this  near  the  fomentation  tank  and  in  the  part  of  the  wet 
rooms  where  the  greatest  amount  of  heat  is  needed.  This 
economizes  both  time  in  labor  and  expense  in  heating  as  some 
heat  will  inevitably  escape  from  the  dryer,  even  though  tightly 
built  and  separate  ventilation  provided  for. 

Enema  and  Douche  Outfit.  These  rooms  should  be  so 
arranged  that  they  are  ventilated  entirely  separate  from  the 
general  treatment  rooms,  best  directly  to  the  outside.  A  bench 
of  drain  board  material  six  feet  long  and  about  twenty-four 
inches  wide  should  be  fitted  over  the  toilet  fixture  in  place  of 
the  ring  and  lid.  At  the  right  hand  end  of  this  should  be 
placed  the  standards  for  hanging  the  enema  and  douche  cans. 
Plate  LIII  shows  a  standard  for  holding  two  irrigating  cans 


APPARATUS  503 

each  of  two  and  a  half  gallons  capacity.  This  standard  consists 
of  two  one-fourth  inch  pipes  fastened  firmly  against  the  wall 
fourteen  inches  apart.  On  these  slides  a  piece  fourteen  inches 
high  and  fourteen  inches  wide  made  of  two  one-half  inch 
upright  pipes  fastened  together  by  three-eighth  inch  pipe. 
Hooks  for  the  ears  of  the  irrigating  can  are  fixed  in  the  upper 
T's  and  thumb  screws  in  the  lower  T's.  Near  the  bottom  are 
fixed  curved  metal  strips  which  hold  the  cans  firmly  and 
prevent  rocking.  This  device  allows  of  placing  the  cans  at 
any  desired  height  and  holds  them  firmly  in  place.  It  is 
simple  and  inexpensive.  Plate  LIV  shows  two  enema  cans 
arranged  for  giving  alternate  hot  and  cold  rectal  irrigation. 

The  enema  and  douche  can  is  made  of  heavy  tin  nine  inches 
in  diameter  and  ten  inches  high.  The  bottom  is  set  up  a  little 
from  the  base  and  slants  forward  to  the  outlet  which  is  bent 
downward  at  its  free  end  to  prevent  breaking  of  the  rubber 
tubing.  The  lower  end  of  this  outlet  is  slightly  above  the  base 
of  the  can  so  that  it  may  set  squarely  on  a  flat  surface.  In  the 
enema  and  douche  room  should  be  provided  a  stationary  wash 
bowl  with  pantry  cocks  or  a  small  sink  with  high  set  faucets  so 
that  the  cans  may  be  filled  directly  from  the  faucets  without 
using  a  dipper. 

Plate  L  V  shows  the  rectal  and  vaginal  tubes  needed  with  the 
enema  and  douche  outfit.  From  above  down  they  are — glass 
vaginal  tube,  glass  enema  tube,  hard  rubber  enema  tube,  bent 
hard  rubber  rectal  tube  for  Murphy  enteroclysis,  prostatic 
cooler  or  psychrophore,  hard  rubber  rectal  irrigation  tube, 
metal  rectal  irrigation  tube.  Besides  these  there  should  be  a 
large  bowel  catheter  or  colon  tube. 

Spray  and  Douche  Controller.  This  apparatus  is  an  absolute 
essential  to  any  treatment  room.  By  means  of  it  the  effect  of 
almost  any  other  treatment  that  may  be  given  to  ambulatory 
patients  can  be  duplicated  and  in  many  cases  the  effects  are 
greater  and  more  lasting.  The  construction  of  a  hydrotherapy 
controller  is  a  very  important  matter,  for  without  perfect  con- 
struction, efficient  work  can  not  be  done  and  the  results  are 
disappointing.  The  construction  must  be  such  as  to  make 
possible  absolute  precision  of  application. 


504 


TECHNIQUE 


There  are  certain  essentials  without  which  satisfactory 
results  are  impossible.  Of  first  importance  is  the  water  supply. 
The  controller  must  be  supplied  with  hot  and  cold  water  by 
pipes  directly  from  reservoirs  or  tanks.  These  pipes  should 
supply  no  other  fixtures.  They  should  be  entirely  independent 
of  all  other  attachments.  If  this  is  not  done  the  temperature 
of  a  douche  stream  or  of  the  spray  will  vary  whenever  water  is 
drawn  from  attached  faucets.  For  example,  if  the  hot  and 
cold  water  supply  to  a  nearby  bath  tub  comes  from  the  pipes 


Fig.  67.     Plan  of  top  of  table  control  shown  in  Plate  L. 

supplying-  the  controller  and,  while  a  douche  is  being  given  at 
115°  F.,  the  attendant  at  this  bath  tub  opens  the  cold  water 
faucet  the  pressure  on  the  cold  water  supply  to  the  douche 
being:  lowered,  the  proportion  of  cold  water  in  the  mixer  will  be 
instantly  lessened  and  just  as  instantly  the  temperature  of  the 
douche  will  shoot  up  ten,  twenty,  or  more  degrees  and  the 
patient  will  be  burned.  Even  with  wholly  independent  supply 
pipes  the  pressure  of  the  incoming-  water  should  be  controlled 
by  pressure  regulators  so  that  the  pressure  of  the  hot  water 
and  of  the  cold  water  may  be  adjusted  to  the  same  number  of 
pounds.  The  temperature  of  the  hot  water  should  be  regulated 
at  the  tank  by  a  thermostat  which  should  be  arranged  for  about 


APPARATUS 


505 


185°  F.  The  cold  water  should  be  supplied  at  a  temperature 
of  40° — 55°  F.,  and  except  in  summer  does  not  usually  require 
cooling". 

There  are  two  types  of  controller — the  table  control  and  the 
wall  control.  The  table  control  is  usually  more  complete  and 
more  satisfactory.  It  is  a  more  eleg-ant  piece  of  furniture  but 
is  likewise  more  expensive.  The  wall  controllers  on  the  market 
are  most  of  them  incomplete  and  less  satisfactory  than  the  table 
control.  However,  the  handling-  of  the  douche  hose  is  more 
convenient  and  with  attention  to  the  essentials  of  construction 
the  wall  control  may  be  made  nearly  as  complete  and  satisfac- 
tory as  the  table  control. 

Plate  L  illustrates  a  hydro- 
therapy  control  table  devised 
by  the  author.  Fig.  67  shows 
the  arrangement  of  the  top  of 
this  table.  As  will  be  seen  it  is 
a  three  unit  controller,  i.  e.,  it 
will  deliver  three  independent 
streams  of  water  at  different 
temperatures.  This  requires 
three  mixers,  two  of  which  sup- 
ply douche  hose — one  for  the 
hot  douche  and  one  for  the  cold 
douche.  The  third  mixer  sup- 
plies the  spray,  the  shower,  and 
the  bidet,  no  two  of  which  at- 
tachments is  it  desirable  to  use  at  the  same  time. 

The  internal  construction  is  as  follows:  The  pressure  regu- 
lators are  attatched  to  the  supply  pipes  just  before  they  divide 
for  the  three  mixers.  These  pipes,  one  for  the  hot  and  one  for 
the  cold  water,  are  one  and  one -half  or  two  inches  in  diameter. 
From  each  are  taken  off  three  one-inch  pipes,  each  of  which 
latter  are  fitted  with  valves  and  check  valves,  the  latter  being 
placed  as  close  to  the  mixers  as  possible.  These  check  valves 
are  an  absolute  necessity  as  otherwise  the  cold  water  pipes  may 
fill  with  hot  water  through  the  mixer,  or  vice  versa,  even  with 
a  very  slight  difference  in  pressure.  Figs.  68  and  69  show 


FiR.  68.     Martinson  mixer, 
showing  its  construction. 


506  TECHNIQUE 

two  styles  of  mixer  valves.  The  first  is  less  expensive  and 
quite  satisfactory.  The  second  costs  a  little  more  but  responds 
a  little  more  evenly  and  hence  is  more  satisfactory.  Where 
used  without  other  valves,  it  must  open  with  the  cold  water 
first,  and  is  therefore  said  to  be  non-scalding. 

From  the  mixer  the  water  passes  over  the  bulb  of  the  ther- 
mometer, which  should  be  placed  as  close  as  possible  to  the 
mixer  so  that  any  changes  in  the  temperature  will  be  registered 
without  delay.  Beyond  the  thermometer  is  the  valve  which 
opens  the  douche  and  regulates  the  volume  and  pressure  of  the 
stream.  Just  beyond  this  valve  the  pressure  gauge  is  attached. 


Fig.  69.    Niedecken  mixer,  showing  working  parts. 

It  is  placed  here  so  as  to  register  the  "using"  pressure,  z.  e., 
the  pressure  administered  to  the  patient.  Still  beyond  this, 
but  below  the  marble  top  of  the  table,  the  inch  pipe  divides  in- 
to two  three-fourth  inch  pipes,  one  for  the  douche  hose  and 
one  to  serve  as  a  vent  which  latter  is  controlled  by  a  valve. 
The  vent  valve  should  be  opened  whenever  the  douche  is  being 
used  in  order  to  keep  going  through  the  mixer  the  large  vol- 
ume of  water,  which  is  always  required  to  maintain  a  constant 
unfluctuating  temperature.  Were  there  no  vent,  the  temper- 
ature would  rise  unduly  when  a  low  pressure  is  being  adminis- 
tered. In  operating  a  controller  with  only  one  douche  unit,  it 
is  impossible  to  secure  absolutely  instantaneous  changes  from 
hot  to  cold.  For  the  method  of  operating  the  douche  units 
the  reader  is  referred  to  the  section  on  spays  and  douches. 


APPARATUS  507 

The  nozzle  attachments  for  the  douche  and  the  shape  of  the 
streams  they  produce  are  shown  in  Fig.  70.  The  upper  figure 
is  the  jet,  or  percussion  douche.  The  middle  figure  shows  the 
spray  douche  and  the  rjsette  attachment  for  producing  it. 


Fig.  70.  Jet  douche,  spray  douche,  fan  douche. 

This  is  used  where  percussion  is  not  desirable  and  a  large  sur- 
face is  to  be  treated.  The  lower  figure  shows  the  fan  douche. 
It  is  produced  by  a  flat  blade  attachment  which  spreads  the 
stream  into  a  sheet  of  water.  Both  the  fan  and  the  rosette  are 
attached  by  screwing  onto  the  jet  nozzle. 

The  stall  for  the  shower  and  spray  should  be  located  about 
eight  feet  from  the  control  table.     The  shower  head  should  be 


508 


TECHNIQUE 


eight  inches  in  diameter.  It  is  best  to  have  it  attached  by  a  ball 
joint  union  so  it  may  face  directly  downward  or  be  inclined 
forward  at  an  angle  of  forty-five  decrees,  so  that  the  patient's 
head  need  not  be  wet.  In  Plate  L  the  shower  head  is  shown 
facing  straight  down.  The  spray  is  constructed  of  four  up- 
right pipes,  to  each  of  which  are  attached  four  rosettes.  The 
upper  row  of  rosettes  are  attached  by  ball  joint  unions  so  that 
they  may  be  adjusted  upward  or  downward  for  individuals  of 
different  heights. 

The  arrangement  of  the  bidet  is  shown  in  Fig.  71.  A  ball 
union  makes  it  possible  to  turn  the  arm  carrying  the  rosette 
out  of  the  way  and  back  against  the  wall  when  it  is  not  in  use. 


Fig.  71.    Plan  of  seat  spray  for  perineal  douche. 

The  stream  should  not  be  a  jet,  but  a  spray  douche,  obtained  by 
a  rosette,  as  it  is  desired  to  cover  a  medium  size  surface  with- 
out percussion.  Since  the  volume  of  water  is  not  large,  the 
shower  valve  should  be  opened  to  act  as  a  vent.  In  the  case  of 
the  two  unit  wall  control  (Fig.  72.)  the  bidet  is  attached  to  the 
same  mixer  that  supplies  one  of  the  douches,  so  that  a  regular 
vent  is  provided. 

Fig.  72  shows  a  spray  and  douche  controller  of  the  wall  type 
devised  by  the  author.  It  consists  of  two  instead  of  three  units. 
One  treatment  combination,  viz.,  a  hot  spray  simultaneous  with 
an  alternate  hot  and  cold  douche  to  the  spine  and  legs  it  is 
impossible  to  give  with  this  machine.  If  the  changes  in  the 
douche  temperature  were  made  by  the  mixer,  it  would  alter 


APPARATUS 


509 


the  temperature  of  the  spray,  hence  this  treatment  is  im- 
practicable without  three  units.  Nevertheless',  for  all  other 
treatments  it  is  equally  as  efficient  as  the  table  control.  On 
the  other  hand,  it  has  the  advantage  that  the  operator  sitting 
on  a  high  stool  facing  the  controller  can  keep  his  finger  in  the 


Fig.  72.     Wall  control,  showing  front  and  side  elevation  plans. 

stream  of  water  from  the  douche  hose,  and  so  add  this  element 
of  protection  to  the  patient  in  case  the  temperature  of  the 
water  should  suddenly  run  up  while  his  eyes  are  on  the  patient 
instead  of  the  thermometer.  Hovvever,  with  the  table  control 
the  thermometer  and  the  patient  are  both  in  front  of  the  opera- 
tor and  but  a  slight  turn  of  the  head  or  eyes  is  necessary  to 
glance  from  one  to  the  other. 


510  TECHNIQUE 

The  wall  control  should  be  supplied  by  independent  pipes  in 
the  same  way  as  the  table  control.  It  must  also  have  pressure 
regulators,  check  valves,  vents,  etc.  The  thermometers, 
valves  for  douches,  spray,  shower,  and  bidet  and  the  pressure 
gauges  are  in  the  same  relative  position  as  in  the  other  type. 
The  wall  control  may  be  fitted  on  an  upright  marble  slab  so 
that  the  pipes  are  concealed  and  only  the  valve  wheels,  ther- 
mometers, pressure  gauges,  faces  of  the  mixers  and  the  douche 
hose  are  visable.  This  makes  a  very  presentable  appearance. 
However,  for  practical  purposes,  the  visable  form  made  of 
nickeled  pipe  is  just  as  good  and  less  expensive.  Having  all 
the  parts  open  to  inspection,  the  mechanism  is  readily  grasped 
by  the  learner.  The  thermometers  should  be  turned  so  as  to  be 
read  from  a  single  observation  point. 

If  ordinary  pressure  reducers,  instead  of  automatic  pressure 
regulators,  are  used  to  equalize  the  pressure  on  the  hot  and 
cold  water  supply,  they  should  be  so  placed  as  to  be  readily 
accessible  as  they  will  need  readjiistment  from  time  to  time  in 
case  of  large  changes  of  pressure  in  the  main  supply.  Let  it 
be  remembered  that  constancy  and  equality  of  pressure  in  the 
hot  and  cold  water  supply  is  the  most  important  requisite  to 
the  satisfactory  operation  of  any  form  of  hydrotherapy  con- 
troller. 


INDEX 


Abdominal  bandage,  415 
Abscess,  224,  318 

alveolar,  229,  460 
Absorption   by 

blood  vessels,  94 

body  membranes,  92 

lymphatics,  94 

skin,   58 

Acapnia,  378,  385 
Acetanilid,  in  fevers,  168 
Acetic     acid    vaginal    irrigation, 

489 
Acid  substances,  effects  of  heat 

and  cold  on,   108 
Aconite,  in  fevers,  168 
Active     hyperemia,    50,    95,    220, 

222 
Affusions,  475 

in  typhoid,  184 
Air,    hot    and     cold     on     blood 

pressure,  99 
Alcohol    in 

fevers,  168 

on  immunity,  391 

pneumonia,  241 

surgical  shock,  385 
Alcoholism,    277,    396 
Alcohol    rub.   424 
Alkaline    bath,    443 

sponge,  424 

Alum   vaginal   irrigation,   489 
Amblyopia,    toxic,   226 
Amenorrhea,    475 
Ammonia,  influence  of  cold  on, 
115 

in  uremia,  359 
Amyl  nitrite,  in  surgical  shock, 

385 

Analgesic  effects,  304,  318 
Anemia,   265 

Anesthesia,   relation     to     shock, 
378 

effect  on  phagocytosis,  389 
Antagonism,  law  of,  82 
Antiphlogistic    effects,    212 
Antioyresis,  clinical,  176 
Antipvretic  effects,  160,  170 


Antipyretics,    medicinal,    168 

Antipyrin,   in    fevers,    168 

Apoplexy,    372 

Apparatus,  h  y  d  r  otherapeutic, 
495 

Appendicitis,   214,  253,  460 

Arrhythmia,  in  heart  disease.  295 

Arteriosclerosis,  relation  of  elas- 
tic tissue  to,  41 

Arthritides,  the  infectious,  250, 
493 

Articular  rheumatism,  acute,  247 
chronic,  250,  343 

Asafoetida  enema,  484 

Asthma,  334 

Astringent  enema,  485 

Ataxia,   locomotor,   312,  475 

Balneology,  25 

Bass  &    Johns,    experiments    of, 

197 
Baths,  398,  430 

air,  superheated,  449 

alkaline,  443 

Brand,  171,  180,  439 

cold,  438 
rationale  of,  187 

diagnostic,  186 

effervescent,  see   Nauheim 

electric  light,  450 

electric   tub,  440 

flowing  bath,  301,  394,  438 

foot,  431 

full  immersion,  436 

graduated,   183,  439 

graduated   shower,   469 

half.  436 

hand  and  arm,  430 

hydro-electric,    440 

leg.  432 

medicated,    443 

Xauheim.  51,  443 

in  heart  disease,  288 

oxygen,  301.  307,  446 

partial    immersion,   430 

rain,  see  sprays 

Russian,  447 

(511) 


512 


INDEX 


saline,  443 

shallow,  264,  440 

shower,    see    sprays 

sitz,  434 

sun,  in  anemia,  268 

in    neurasthenia,   272 

tub,   437 

Turkish,  4<9 

vapor,  448 
Hath  tubs,  500 
Bed  bath,  181,   182 
Bier's    hyperemia,    223 
Hillary  colic,  324 

inflammations,   252 
BiUousness,  364 
Hlanket  packs    454 
Blood,  effects  on  composition  of 
100 

reaction  of,  108 

viscosity  of,  105 
B'nod  poisoning,  230 
Hlood  pressure,  47,  79,  89 

effects  of  heart  beat  on,  89 

effects  of  volume  of  fluid  on, 
89,   91 

effects  of  vascular  calibre  and 
action  on,  95 

in    Bright's   disease,  351 

laws  of  effects  on,  97 
Blood  vessels,  41 

action  of,  46,  95,  286,  381 

calibre  of,  95,  381 

capillary   loops   in    skin,   41 

effects  of  heat  and  cold  on,  49 

pumping  action  of,  97,  286,  381 

in  malaria,  201 

reaction    in,   49 
Boils,  230 
Bright's   disease,  350 

acute,  354 

chronic,  356 
Bronchitis,    acute,   333 

chronic,  335 
Bronchoprieumonia,   242,   493 

in   measles,  206 
I'.ruises,   326 
Rums,    325 

Caffein,   see   coffee 

Calorie,    20 

Calorimeters,    145 

Carbolic  acid  vaginal  irriga- 
tion, 489 

Carbon  dioxide,  effects  on  blood 
vessels,  51 


influenced    by   heat   and    cold, 
128,  190 

in  fevers,  190 

in  Xauheim  bath,  443 

in  surgical  shock,  see  acapnia 

respired  by  skin,  59 
Carbuncles,   230 
Cardiac  changes  in  shock,  380 
Catarrhal  jaundice,  252 
Cathartics,   in   edema  of  nephri- 
tis, 357 

Cellulitis,  pelvic,  254 
Centripetal  friction,  425 
Cerebral  congestion,  214,  282 
Charcoal   poultice,  418 
Chest  packs,  413 
Chloral,  on  immunity,  391 
Chloroform,  on  immunity,  391 
Chlorides,  effect  of  cold  on,  120 
Cholangitis,  252 
Cholecystitis,  252,  493 
Chorea,  309    475 
Circulation,  62 

balance     between     reflex     and 
hydrostatic  effects,  86 

blood    pressure,  89,   see    also 
blood    pressure 

composition  of  blood,  100 

hydrostatic  effects  on,  78 

in  inflammations,  218 

in    pneumonia,    232 

in  surgical  shock,  379 

in  typhoid  fever,  188 

quantity  of  fluid  in,  52 

effects  on  blood  pressure,  91 

reflex  effects  on,  62 
Clark's  column,  66,  68 
Clay  and  glycerine  poultice,  417 
Coal  tar  products,  in  fever,   168 
Coffee,  a  cause  of  fever,   161 

effects  on  purins,  360 
Coil,  cold  water,  411 
in  typhoid,  185 

hot  water,  407 

Leiter,   412 
Cold  air,  in  pneumonia,  234 

on  blood  pressure,  99 
Cold,  effects  on 

antibodies,  110 

ammonia,  115 

blood  pressure,  50,  79,  98 

blood  vessels,  50,  78 

carbon      dioxide      elimination, 
128 

carbonaceous  metabolism,  125 


INDEX 


513 


chlorides,  120 

composition  of  blood,  100 

extractives,  118 

fever,  171 

glycogen  content  of  man,  280 

heat  elimination,  147,  151 

heat  oroduction,  147,  150 

muscular  capacity,  130 

nervous  system  in  typhoid,  187 

nitrogenous   metabolism,    111 

oxygen  absorption,  128 

perspiration,  57 

phosphoric  acid,  119 

purin,  116 

red  cells,  101 

respiratory  quotient,    128,  280 

skin   muscles,  40 

sulphates,  120 
•  sweat  glands,  57 

toxin    elimination    in    typhoid, 
190 

urea,  115 

uric  acid,  116 

white  cells,  101 
Cold,  hydrostatic  effects  of,  78,  81 

intrinsic   effects   of,   29 

local  applications  of,  397,  409 

reaction  to,  30 

reflex  effects  of,  73 
Cold-blooded  animals,  28 
Cold    friction,    effects    on    vaso- 
motors,  50 

in  fever,  189 

in   heart  disease,  288 

in  shock,  383 
Cold  plunge,  264 
Cold  treatments,  see  distinctive 

word  in  each 
Colds,  333 
Colic.  323 

biliary,  324 

intestinal,  324 

renal,  324 

Colitis,  mucous,  256,  493 
Collapse,  376 
Colocyster,  480 
Compresses,  404,  405,  409,  412 

cold  in   typhoid,   184 

heating,  397,  412 

hot  gauze,  404 

joint.  416 

medicated,  417 

revulsive,  405 

throat,  416 
Conjunctivitis,  225 
33 


Constipation,  298,  475,  492 
Continuous      flowing   bath,    301, 

394,  438 
Controller     for     sprays     and 

douches,  503 

Convection,  heat  loss  by,   141 
Coryza,  acute,  333 

chronic,  492 
Cough,  333 

in  pneumonia,  238 
Cravat,  ice,  410 

Creolin,  vaginal  irrigation,  489 
Crile,  investigations  of,  376, 385 
Croup,  333 
Cystitis,  257,  493 

Dachryocystitis,  225 
Depletion,  212 

by      simultaneous      heat     and 
cold,  213 

by  heat  alone,  215 

by  cold  alone,  215 
Depressant  effects,  32,  72 
Derivation,  80,  212 

areas  for,  83 

definition  of,  212 
Dermatomes  of  Head,  65 
Dermographism,  37 
Diabetes,  278 
Dialysis,  24 

Diaphoretic  effects,  337 
Diaphoretics,  medicinal,  170,  357 
Diet,  in  Bright's  disease,  351 

in  diabetes,  279 

in  uremia  and  eclampsia,  361 

low     proteid,    metabolism    in 
122 

meat 

effect  on  erdurance,  137 
effect  on  liver,  359 

purin-free  in  gout,  344 

vegetable  in  gout,  345 
Digitalis,  in  fevers,  118 

in  surgical  shock,  386 
Diuresis,  effects  of 

cold  bath  on,  190 

refrigerants  on,  170 

sweating  on,  338 
Diuretic  effects,  339 
Douches,  467,  471,  507 

cold  as  a  tonic,  263 

vaginal,  see  vaginal  irrigation 
Dover's  powder,  in  fever,  170 
Dripping  sheet  rub,  263,  421 
Drug  habits,  394 


514 


INDEX 


Dryer  for  treatment  rooms,  502 
Duodenal  ulcer,  319 
Dysmenorrhoea,  323 
Dyspepsia,  275,  364 

Eclampsia,  358 

Kdeir.a,  absorption  of,  94 

complicating  heart  disease,  293 

in   Bright's  disease,  353 

of  lungs  in  heart  disease,  294 
Effects,  analgesic,  304 

antiphlogistic,  212 

antipyretic,  160 

depressant,  32,  72 

derivative,  80,  212 

diaphoretic,  337 

diuretic,  339 

double,  88 

emmenagogic,  297 

excitant,  295 

expectorant,  331 

hemostatic,  370 

hydrostatic,  78 

intrinsic,  29 

metabolic,    111,    125,   278,   337, 
341 

oxytocic,  297 

peptogenic,  363 

primary,  31 

principles  of,  27 

reactionary,  30 

reflex,  62 
of  cold,  73 
of  heat,  76 

retrostatic,  80 

secondary,  31 

sedative,  72,  300 

stimulant,  72,  260,  295 

tonic,  32,  260 

vascular,  49 
Effervescent  bath,  see  Nauheim 

bath 

Eggs  in  anemia,  265 
Elastic  tissue  of  s'  in,  40 
Electric  light  bath,  450 
Electric  light  cabinets,  501 
Electric  tub  baths.  440 
Electro-thermal   baths,  440 

(.acV-s,  460 

Emmenagogic  effects.  297 
Endocarditis,    in     scarlet     fever. 
209 

in  rheumatic  fever.  249.  494 
Endometrtis,  254 
F'u-mata.  398,  476 


asafoetida,  484 

astringent,- 485 

cold,  in  typhoid,  185 

glycerine  and  Epson  salts,  485 

graduated,  478 

medicated,  481 

molasses,  484 

oil,  484 

outfit  for,  502 

plain  water,  477 

quassia,  486 

quinin,  486 

saline,  481 

soap-suds,  483 

starch,  485 
Epistaxis,  370 
Erectores  pilorum,  40 
Ergograph  experiments,  131,272 
Erysipelas,  227 
Ether,  method  of  giving,  375 

on  immunity,  391 
Exercise,  effect  on  lymph  move- 
ment, 53 

effect  on  reaction,  35 

in  diabetes,  280 
Expectorant  effects,  331 
Evaporation,  effect  on  reaction, 
36 

heat  loss  by.   142 

Earadic  tub  bath,  441 
Eatigue  poisons,  135 
Fever,  160 

causes  of,  161 

circulatory  failure  in,  165 

heat  mechanism  in,  174 

hydrotherapy  in,  163,  170 

manifestations  of,  162 

medicinal   antipyretics   in,    168 

principals  of  treatment.   162 

rheumatic,  247 

scarlet,  206 

treatment  of,  179 

typhoid,  179 

variations  that  produce,  175 
Elexner's  serum,  251 
Fluxion.  216,  222 

definition   of,  212 
Fomentations,   400 
Fomentation  tank,  498 
Foot  baths,  431 
Foot  tubs,  500 
Fractures,  326 
Friction,  425 

cold    mitten.   262.   418 


centripetal,  425 
dry,  430 
tonic,  397,  418 

Frog,  a  cold-blooded  animal,  28, 
140 

Galvanic  tub  bath,  441 
Gangrene,  diabetic,  494 
Gastrectasia,  364,  368 
Gastric  lavage,  in  dyspepsia,  368 

in  surgery,  392 
Gastric  secretion,  effect  of  cold 

on,  365 

Gastric  ulcer,  319 
Gastroptosis,  364,  367 
Glands,  sebaceous,  58 

sweat,  54 
Glaucoma,  226 
Glycerine     and       Epsom     salts 

enema,  485 

Glycerine  and  white  clay  poul- 
tice, 417 
Goitre,  313 

Gonorrhoea,  258,  493,  494 
Gout,  343 
Grippe,  209,  492 
Gymnastics,  resistant,  289 

Half-bath,  436 
Headache,  327 
Heart,  beat,  effect  on  blood 

pressure,  89 

force  of  in  infections,  166 
disease,  valvular,  283,  494 

fatty,  295 

failure  in  typhoid,  188 
innervation  of,  67 
peripheral,  45,  52,  286 
reflex  arc  to,  67 
Heat,  loss,  141,  149,  151,  171,  174 
mechanism,  139,  174 
production,   140,   144,  148,  150, 

171,  174 
regulation,  152 

Heat,  absorption  and  communi- 
cation of,  17 
effects   on, 

blood  pressure,  79,  98 
carbon   dioxide,   128 
carbonaceous       metabolism, 

128 
composition    of   blood,    102, 

108 

fever,   172,   186 
muscles  of  skin,  40 


INDEX  515 

muscular  capacity,  132 

nitrogenous  metabolism,  120 

oxygen,  128 

red  cells,  100 

respiration,   125 

sweat  glands,  57 

white  cells,  102 

hydrostatic  effects  of,  78 

intensity  of,  19 

latent,  21 

local  applications  of,  397,  400 

physics   of,   18 

quantity  of,  heat  units,  20 

radiant,  408 

reaction  to,  32 

specific,  20 
Heat  stroke,  282 
Hemogoblinuria,   199 
Hemorrhage,  gastric,  371 

in  typhoid,  191 

pulmonary,  371 

relation   to   shock,  378 

uterine,  371 
Hemorrhoids,  319,  494 
Hemostatic  effects,  370 
Henderson,    work     on     acapnia. 
378 

work  on  veno-pressure,  380 
Hilton's  law,  65 
Hip  and  leg  pack,  458 
Hip  pack,  see  plevic  pack 
Homeothermic  animals,  28 

reaction  of,  28 
Hot  and  cold  treatments, 

douch,  474 

foot  bath,  432 

leg  bath.  433 

rectal  irrigation,  480 

shower,  470 

sitz,  435 

spray,  see  shower 

to  head,  406 

to  spine,  405 
Hot  water  bottles,  407 
Hydrogogue    action    of    hyper- 
tonic  solutions,  93 
Hydrostatic  effects,  78 

balance    between — and    reflex 
effects,  86 

secondary,  81 
Hyperchlorhydria,  368 
Hyperemia,    active,   50,   95,   216. 
218 

arterial,  see  active 

Bier's  223 


516 


INDEX 


collateral,  213 
passive,  50,  95,  219,  223 
Hyperthyroidism,  see  goitre 
Hypertonic  solutions,  92,  483 
llypochlorhydria,    363,    474,    494 
Hypodermoclysis,  95 
Hysteria,  274 

.'' 

Ice  bag,  411 
effect  of  over  heart,  67 
in  heart  disease,  285 
in  goitre,  315 
with  hot  packs,  459 
Ice  cap,  see  ice  bag 
Ice  cravat,  410 
Ice  pack,  410 

in  pneumonia,  237 
Ice  rub,  422 

in  typhoid,  184 
Ice  water  coil,  226 
Icterus,  432 
Immunity,  109,  164,  168,  197,  389, 

391 

Inebriety,  277,  396 
Infections,  post  anesthetic,  389 
see  also  fevers,  inflammations, 

puerperal, 
Inflammations,  212 
biliary,  252 
deep-seated,  318 
denned,  218 
of  eye,  225 
pelvic,  254 

principles  of  treatment,  219 
pathogenesis  of,  218 
superficial,  319 
treatment  of,  225 
Influenza,  209,  492 
Insanity,  394 
Intestinal  colic,  324 

stimulants,  298 
Insomnia,  277,  306,  494 
Internal  hydrotherapy,  24 
Intrinsic  effects  of  cold,  29 
of  heat,  30 
time  factor  in,  32 
Iritis,  225 
Iron  in  anemia,  265 

organic,  266 
Isotonic    solutions,  93 
Ivy,  poisoning  by,  232 

Jaundice,  see  icterus 

catarrhal,  252 
Joint  compress,  416 


Keratitis,  225 

Kidneys  in  typhoid,  189,  191 

Lactic  acid  as  fatigue  poison,  135 
Latent  heat,  21 
Law,  Berthollet's  346 
Dastre-Morat,  82 
Hilton's,  65 
Muller's  97 
of  antagonism,  82 
of  balance  between  reflex  and 
hydrostatic  effects,  87 
Leg  bath,  432 

pack,  459 
Leg  tubs,  500 
Leucocytes,    effects    of    alcohol 

on,  168,  391 
anesthetics  on,  391 
coal  tar  products  on,  168 
cold  on,  100,  189 
heat   on,    102,  200 
quinin  on,  169,  200 
in  fevers,  163,  164 
in  inflammations,  219 
in  malaria,  198 
Leucocytosis,  from  cold,  100 

in  malaria,  198 
Leucomaines,  a   cause  of  fever, 

160 
Leucopenia,  in  malaria,  200 

in  typhoid,  189 
Light,  26 

Lithium  in  gout,  345,  348 
Liver,  congestion  of,  293 

effects  of  meat  diet  on,  359 
Locomotor  ataxia,  312,  475 
Lumbago,  322,  474,  494,  see  also 

rheumatism 
Lymphatics,  41 

absorption  by,  41,  53 
effects  of  stimulation  on,  53 
lymphatic  hearts,  43 
movements  of,  44 
quantity  of  fluid,  53 
valves  of,  43 
Lysol  vaginal  irrigation,  489 

Mania,  394 
Malaria,  194,  475 
Maragliano,  experiments  of,  201 
Massage,  effects  on  blood  cells, 
103 

effects  on  lymphatics,  53 

in  anemia,  267 


INDEX 


517 


in  diabetes,  280 

in  heart  disease,  287 

in  rheumatism,  348 
Mastoiditis,  214,  228,  460,  493 
Measles,  204 

Meat  diet,  effect  on  liver,  359 
Mechanical  stimuli,  23 

effects, 

on  blood  pressure,  98 
on  carbon  dioxide  and  oxy- 
gen, 129 
on  muscular  capacity,  133 

vibration,  in  heart  disease,  288 
Medicinal  antipyretics,  168 
Meningitis,  214,  251,  460 
Menstruation  in  typhoid,  192 
Menthol  rub,  425 
Mercury,  specific  heat  of,  20 

bichloride     vaginal    irrigation, 

488 

Metabolic  diseases,  341 
Metabolism,  carbonaceous,  125 

nitrogenous,  111 
Migraine,  328 
Mineral  waters,  25 

absorption  of,  59 

in  rheumatism,  348 
Mitten  friction,  see  friction 
Morphin,    effect   on   phagocytes, 

390 

Morphin  habit,  396 
Mortality,  in  typhoid,  192 
Mucous  colitis,  256 
Muscular  tissue  of  skin,  40 

capacity,   13 
Myalgia,  322 
Myelitis,  311 
Myocarditis,  247 

diphtheritic,  166 

Nauheim  bath,  51,  443 

effect  on  blood  pressure,  99 

in  heart  disease,  288 
Naumann,  experiments  of,  63 
Nephritis,  350 

acute,  354 

chronic,  356 

in  scarlet  fever,  208 

in   typhoid,   191 

sweat  glands  in,  57 
Nerves  of  skin,  61 

secretory,  72 

^temperature,  61 

vasomotor,  distribution  of,  41, 
44 


visceral,  72 
Nervous  system  after  cold  bath, 

187 
Neuralgia,  215,  320 

inflammatory,1  321 

toxic,  320 
Neurasthenia,  269 

splanchnic,  273,  494 
Neutral  bath,  437 

douche,  473 

electric  tub  bath,  440 

pack,  463 

shower,  469 

sitz  bath,  435 

temperature,  38 
Nitrogen  economy,  113 
Nitrogenous  metabolism,  111 
Nitroglycerin,  in  surgical  shock, 
386 

Obesity,  341 

with  fatty  heart,  295 

rheumatism  with,  347 
Oertel  method,  291 
Oil  enema,  484 

rub,  428 

Ophthalmia,  225 
Osmosis,  24,  92 
Osteomyelitis,  214,  217,  318 
Otitis  media,  227 
Ovaritis,  254 
Oxygen,  effects  of  heat  and  cold 

on,  128,  190 

Oxygen  bath,  301,  307,  446 
Oxytocic  effects,  297 
Ozone,  on  glycosuria,  281 

Packs,  398,  454 
blanket,  454 
chest,  413 

electro-thermal,  460 
evaporating,  462 
half-pack,  465 

heating,    464,   see    also    com- 
presses 

pelvic,  465 

trunk,  465 
hip  and  leg,  458 
hot  and  heating  trunk,  466 
hot  pelvic,  458 
hot  trunk,  457 
hot,  with  ice  bags,  459 
ice.  410 
leg,  459 
neutral,  463 


518 


INDEX 


revulsive  pelvic,  458 

revulsive  trunk,  457 

sweating,  464 

wet  sheet,  461 

in  typhoid,  184 
I 'ail  pour,  263,  475 
Pain,  relief  of,  304,  318 

in  pneumonia,  238 
Palpitation,  in  heart  disease,  295 
Pancreatitis,  subacute,  253 
Paraesthesias,  relief  of,  305 
Paralysis  agitans,  310 

spastic  spinal,  311,  475 
Passive   hyperemia,   50,   95,   219, 

223 

Pathogenesis,  of  fever,  160 
of  inflammation,   174,  218 
Pelvic,  cellulitis,  254 

inflammations,  254 

pack,  heating,  465 
hot,  458 
revulsive,  458 

peritonitis,   254 
Peptogenic  effects,  363 
Perforation  in  typhoid,  191 
Pericarditis,  246 
Peripheral  heart,  45,  52,  286 

measures  which  stimulate,  286 
Peritonitis,  214,  460 

pelvic,  254 
Phagocytosis,  in  fevers,  163,  168 

in  malaria,  198 

effects    of   anesthesia    on,  389, 
391 

cold  on,  109 

drugs  on,  168 

morphin  on,  390 
Pharyngitis,  229,  493 
Phases  of  reaction,  33 
Phenacetin.  in  fevers,  168 
Phlebitis,  256 
Phosphoric   acid,   effect   of  cold 

on,  119 
Physiologic  agents,  27 

effects,  principles  of,  27 

sti*rulants,  260 

therapy,  realm  of,  155 
Pilocarpin,  in  fevers,  170 
Pleurisy,  215,  244,  475,  492 

Complicating  typhoid,  191 
Plunge,  cold,  264 
Pneumonia.  232,  460,  475 

complicating  typhoid,  190 
P;>ikilothermic  animals,  28 
Poisoning,  ivy,  232 


systemic,  342 

Poultices,  397,  417 

Prescription  writing,  490 

Properties  of  water,  17 

Proctoclysis,     Murphy    method, 

482 

absorption   of  fluid,  93 
in  surgical  collapse,  383 

Prostatic  hypertrophy,  493 

Prostatitis,   258,   475 

Proximal  application,  74,  410 

Psychic  attitude,  effect  on  reac- 
tion, 36 

Puerperal  infection,  214,  254,  460 

Pulmonary  congestion,  214,  333 
hemorrhage,  371 

Purin,  diathesis,  343 
a  cause  of  fever,  161 
as  fatigue  poison,  136,  138 
effects  of  coffee  on,  360 
effect  of  cold  on,  116 
in  gout,  343 

Pyrexia,  see  fever 

Quassia,  enema,  486 
Quinin,    enema,   486 

in  fevers,  169 

in  malaria,  194,  199 

in    pneumonia,   239 

prophylactic  use  of,  195,  197 

protozoan  immunity  to,  197 

Radiant  heat,  408 
Radiation,  heat  loss  by,  141 
Reaction,   30 

ability,  test  of,  37 

circulatory,  33,  49 

conditions  influencing,  35 

deep  reflex,  73,  76 

incomplete,  34 

in  blood  vessels,  49 

in   malaria,  204 

nervous,   33 

of    short    cold,    31 

phases  of,  33 

rationale  of,  31 

repeated  34 

suppressed,  34 

thermic,  33 

time  factor  in,  32 

to  heat,  32 

types  and  degrees  of,  34 
Rectal  injection,  see  enemata  . 
irrigation    479 

tenesmus,  322 


ulcer,  319 
Red  cells,  effect  of  cold  on,  100 

effect  of  heat  on,  102 
Reflex  arc,  65 

areas,  64,  69 

effects,   62 

classes,  72 

Refrigerants,  in  fever,  170 
Resistant  gymnastics,  289 
Respiration,    125 

by   skin,   59 

Rest,  in  heart  disease,  285 
Retrostasis,   80 
Revulsion,  defined,  217,  399 
Revulsive  compress,  405 

douche,  473 

pack,  457,  458 

sitz  bath,  435 
Rheumatic  fever,  247 
Rheumatism,  chronic  gouty,  278, 
343 

with  emaciation,  348 

with  obesity,  347 
Risley,  experiments  of,  122 
Romberg  and  Passler,  researches 

of,  165,  188,  236 
Rubner,  chart  on  heat  loss,  143 

experiments  of,  128 
Rubs 

alcohol,  424 

cold  towel,  263,  420 
in  typhoid,  184 

dripping  sheet,  263,  421 

dry,  430 

ice,  184,  422 

menthol,  425, 

oil.  428 

vinegar  and   salt,  424 

wet  hand,  262,  420 

wet  sheet,  263,  421 

witchhazel,  425 
Rubs  and  frictions,  398,  425 
Russian  bath,  447 
Russian  bath  room,  502 
Saline  bath,  443 

sponge,  424 

Salpingitis,  214,  254,  460  492 
Salt  and  vinegar  rub,  424 
Salt  glow,  263,  422 
Salt,  relation  to  edema,  352 
Scarlet  fever,  206 
Srhott    treatment,   289 
Schuller,   experiments  of,  62,  78 
Sciatica,  215,  321,  474 


INDEX  519 

Sebaceous  glands,  58 
Sedative  effects,  72,  300 
Sedatives,  general,  301 

local,  304 

pure,    300 

tonic,  303 
Septicemia,  230 
Serum,   Flexner's,  251 
Shampoos,  398,  452 
Sheet  pack,  461 

in  typhoid,  184 
Sheet  rub,  wet,  263,  421 

dripping,  263,  421 
Shock,   surgical,  376 
Shower  bath,  see  sprays 
Sinsuoidal  electricity,  in  neuras- 
thenia, 274 

tub  bath,  441 
Sitz  bath,  434 
Sitz  tubs,  501 
Skin,  39,  54 

heat,  regulation  by,  60 

respiration  by,  59 

vicarious  functions  of,  56 
Soap  suds  enema,  483 

vaginal  irrigation,  488 
Soap   wash,   425 
Specific  heat,  20 

Spinal  paralyses,  spastic,311,  475 
Splanchnic  efferent  nerves,  66,  72 

neurasthenia,  273 
Spleen,  effects  on  distribution  of 

blood  cells,  103 
Sponging,  397,  423 
Sprains,  326 
Sprays,  398,  467,  470 
Starch,  enema,  485 
Starling,  work  of,  92 
Steam  boxes,  400,  499 
Steam  inhaler,  334 
Stimulant  effects,  72,  260,  295 
Stimulants,  260 

drug,  defined,  260 

intestinal,  298 

uterine,  297 

vesical,  297 
Stimuli,  mechanical,  23,  129 

thermic,  22 

Stomach,  reflex  arc  to,  68 
Stupes,    404 
Strychnin,  as  a  general  tonic,  137 

in  pneumonia,  240 

in  surgical  shock,  387 

in  typhoid,  188 
Sulphates,  effect  of  cold  on,  120 


5X0 


INDEX 


Sun  baths,  in  anemia,  268 

in  neurasthenia,  272 
Sunstroke,  282 
Surgery,  after-treatment,  389 

hydrotherapy  in,  373 

immediate  care,  375 

preparatory  treatment,  373 

relation    to    physiologic    ther- 
apy, 156 
Surgical  shock,  376 

contributing  causes,  377 

drugs  in,  385 

hydrotherapy  in,  383 

treatment  of,  382 
Sweat  glands,  54 

in  nephritis,  57 

perspiratory  influences,  57 

vicarious  functions,  56 
Swedish  shampoo,  452 

Talcum  rub,  430 

Technique  of  hydrotherapy,  397 

classification,  397 

glossary  of  terms,  398 
Temperature,     common     names 
of,  38 

nerves  of,  61 
Tenesmus,  322 
Therapeutics,  155 
Therapy,  basic  principles  of,  159 

physiologic,  realm  of,  155 

principles  of,  27 
Thermic  stimuli,  22 
Thermometers,  19 
Thermotherapy,  17,  27 
Throat  compress,  heating,  416 
Tobacco  blindness,  227 
Tonic  effects,  32,  260 

frictions,  397,  418 

sedatives,  303 

Tonics,  hydriatic  vasomotor,  288 
Tonsillitis,  229 

in  scarlet  fever,  20 
Tonus   waves,  48 
Towel  rub,  see  rubs 
Tracoma,  226 

Traube-Hering  waves,  46,  379 
Trauma,  relation  to  shock,  377, 

388 
Trunk  pack,  heating,  464 

hot,  457 

Tuberculosis,  pulmonary,  275 
Turkish  bath,  449 

shampoo,  453 
Turpentine  enema,  484 


Tympanites,  in  typhoid,  192 
Typhoid   fever,    179 

hot  treatment  in,  186 

cold  treatment  of,  180 

Ulcer,  duodenal,  319 

gastric,  319 

rectal,  319 

trophic,  494 

varicose,  474,  494 
Urea,  effect  of  cold  on,  115 

in  uremia,  359 
Uremia,  358,  493 

acute,  361 

Urethritis,  specific,  258,  475 
Uric   acid,    effect   of   caffein    on, 
360 

effect  of  cold  on,  116 

effect  of  heat  on,  121 

endogenous,   in   gout,  358 

formation  and  destruction  of, 
344 

Vaginal  irrigation,  398,  486 
Vaginitis,  258 
Valvular  heart  disease,  283 
Vapor  bath,  448 
Varicose  ulcer,  474 
Vasomotor  center,  62,  66 
paralysis  of,  in  fevers,  165 

in  shock,  379 

Vasomotor  nerves,  41,  44,  62 
Vasomotors,     effect     on     blood 

vessels,  44,  62 
failure  in  fevers,  165 
in    shock,   379 
in  typhoid,  188 

Vasomotor  tonics,  in  fevers,  167 
in  heart  disease,  286 
in  surgical  shock,  383 
Veno-pressor     mechanism,    380, 

381 
Vesical  stimulants,  297 

tenesmus.  322 

Vibration,  in   heart  disease,  288 
Vinaj  and  Maggiori,  experiments 

of,  130 

Vinegar  and  salt  rub,  424 
Vinegar   vaginal    irrigation,    489 
Viratrum  viride,  in  fevers,  168 
Vomiting,  494 

Warm-blooded  animals,  28 
Water,  expansion   of,   18 
mineral,  25.  345,  348 


INDEX  521 

properties  of,  17  in  typhoid,  184 

Water  bottles,  hot,  407  Wet    sheet    rubs,    263,   421,    see 

Water   drinking,   cold,   effect   on  rubs 

blood  pressure,  98  White  cells,  see  leucocytes 

effect  on  urea  excretion,  121  Win,.ernitz  coil,  407 

in  dysnepsia,  366  in  dyspepsia,  365 

in  pneumonia,  239  in  typhoid,  185 

in  surgery,  375,  391  Winternitz  pack,  407,  466 

Wet  hand  rub,  262,  420,  see  rubs  in  dyspepsia,  365 

Wet  sheet  pack,  461,  see  packs  Witchhazel  rub,  425 


Date  Due 


PRINTED  IN   U.S.*.  CAT.     NO.     24      161 


A  000510244  7 


WB520 
A131p 


Abbott,  George  Knapp. 

Principles  and  practice  of 
hydrotherapy 


3 

S 


WB520 
A131p 

Ab£f.  George  Khapp.      W14 

"^  ~  SU.  of  ^^ 


MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA  M 
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